tourette's%20syndrome%20-and-%20other%20tic%20disorders
TOURETTE'S SYNDROME & OTHER TIC DISORDERS
Tics are sudden, rapid, non-rhytmic, repetitive, motor movements or vocalizations. The mean age of onset is approximately 5 years old.
Tourette's syndrome is the most common form of tic disorder.
There is a strong genetic component showing a 10- to 100-fold increase in the rates of tics and Tourette's syndrome among first-degree relatives of Tourette's syndrome patients.
Simple motor tics are restricted to a single or a few muscle groups and last less than a fraction of a second.
Complex motor tics involve larger muscle groups, usually last longer and appear purposeful and goal-directed.

Principles of Therapy

  • May be considered if symptoms interfere with normal functioning
  • Successful treatment of comorbid disorder usually decreases tic severity
  • There is no cure for Tourette syndrome (TS); aim of pharmacological therapy is to reduce the frequency and severity of tics
  • Goals should be to relieve tic-related discomfort/embarrassment and to allow the patient to function as normally as possible
  • Choice of treatment depends on the following factors: severity of symptoms, address the most problematic symptom(s), patient’s sense of urgency for treatment, and patient’s aversion to risk of likely or unlikely adverse effects

Pharmacotherapy

Alpha-Adrenergic Agents

Clonidine

  • May be preferred over antipsychotic medications because of decreased risk of acute and long-term side effects
  • Useful for children who are hyperactive, impulsive and disinhibited
  • Has been shown to improve tics and attention-deficit/hyperactivity disorder (ADHD) 

Guanfacine

  • Found to be less sedating and less hypotensive than Clonidine
  • Has been shown to improve tics and attention-deficit/hyperactivity disorder
  • Ensures more patient compliance as it can be given once at bedtime or 2x daily as compared with 3-4x daily doses of Clonidine

Neuroleptics

  • Neuroleptics are considered the most effective drugs

Conventional/Typical Antipsychotics

  • Haloperidol
    • Side effects tend to limit use and there are other agents that may be better tolerated
    • Many case reports and placebo-controlled studies have shown effectiveness
  • Pimozide
    • Shown to be effective in Tourette syndrome (TS)
    • May be more effective than Haloperidol but studies comparing the 2 agents have been conflicting

Selective Dopamine D2 Receptor Antagonists

  • Sulpiride
    • A small number of uncontrolled studies have shown Sulpiride to be effective in treating tics in 59% of patients
    • Improves aggressive obsessive-compulsive behavior and mood
  • Tiapride
    • Small number of studies have shown that it reduces tics without affecting cognitive impairment
  • Tetrabenazine
    • Depletes dopamine by inhibiting vesicular monoamine transporter type 2
    • As effective as the typical neuroleptics but does not cause tardive dyskinesia
    • Studies have shown to be effective in hyperkinetic movement disorders

Atypical Antipsychotic

  • Aripiprazole 
    • Indicated for treatment of Tourette’s disorder in pediatric patients 6-18 years
    • Acts as antagonist at D2 receptors under hyperdopaminergic conditions and displays agonist properties under hypodopaminergic conditions
  • Risperidone
    • Extrapyramidal syndrome side effects are usually less compared with conventional antipsychotics
    • Most extensively studied of the atypical antipsychotics in the treatment of Tourette syndrome
    • Several studies show Risperidone is effective for Tourette syndrome
    • Has been advocated as 1st-line agent in patients with tics & obsessive-compulsive disorder symptoms
    • Based on a retrospective chart review, it has been shown to decrease aggressive behavior in patients with Tourette syndrome

Selective Serotonin Re-uptake Inhibitors (SSRIs)1

  • Considered 1st-line agents in patients with significant depression or obsessive-compulsive disorder symptoms
  • May improve tics in some patients, may worsen them, or may have no effect on tics in others
  • Eg Fluoxetine

Selective Noradrenaline Reuptake Inhibitor (SNRI)

  • Atomoxetine
    • A nonstimulant found to be modestly effective in the treatment of Tourette syndrome-related attention-deficit/hyperactivity disorder (ADHD)

Tricyclic Antidepressant1

  • Clomipramine
    • Has nonselective reuptake blocking properties that relieve symptoms of obsessive-compulsive disorder (OCD) 

Stimulants2

  • Considered 1st-line agents in patients with attention-deficit/hyperactivity disorder
  • Methylphenidate may be better tolerated than Dextroamphetamine in patients with Tourette Syndrome
  • Methylphenidate and Clonidine have additive benefits in Tourette syndrome and attention-deficit/hyperactivity disorder

Botulinum Toxin

  • Involves local intramuscular (IM) injection of the toxin to the affected muscle site
  • Most useful for persistent, focal motor (eg eye blinking, neck and shoulder tics), and sometimes vocal tics by temporarily weakening the affected muscles
  • Tic and tic urges have been shown to improve
  • Effects can be seen in the absence of gross weakness
  • Lasts for only 12-16 weeks

Other Agents Reported to Improve Tics

  • Topiramate
    • Alternative agent in patients with mild but troublesome tics who are intolerant or unresponsive to other treatment agents
    • More studies are needed to confirm safety and efficacy
  • Baclofen, Clonazepam, Fluphenazine, Levetiracetam, Lithium, Naloxone, Nicotine, Olanzapine, Quetiapine, Talipexole, Ziprasidone

1Please refer to Obsessive-Compulsive Disorder Management Chart for detailed discussion on treatment.

2Please refer to Attention Deficit/Hyperactivity Disorder Management Chart for detailed discussion on treatment

Non-Pharmacological Therapy

Behavioral Treatment

  • Individualized, specifically based on the needs of the patient
  • May be a treatment option for patients who prefer non-pharmacological treatment or patients intolerant or unresponsive to pharmacological therapy
  • Most disabling symptoms should be targeted first
  • Interventions which have been used in the treatment of tics:
    • Cognitive therapy 
      • Recommended as 1st-line treatment for patients with tic disorders and obsessive-compulsive disorder (OCD)
    • Habit-reversal training consists of tic-awareness training and competing-response training
      • May be effective in improving tics and controlling symptoms in Tourette syndrome (TS) based on findings from unblinded trials and a controlled trial with blinded outcome assessment
    • Massed negative practice
    • Assertiveness training
    • Relaxation therapy
    • Awareness training (including self-monitoring)
  • Comprehensive Behavioral Intervention for Tics (CBIT) composed of habit reversal training, relaxation training and functional interventions addressing situations which sustain or worsen tics is a recommended treatment option for patients with tics

Deep Brain Stimulation

  • An invasive neurosurgical procedure reserved for severe refractory cases of Tourette syndrome
  • Considered to be an experimental option for intractable cases
  • The largest published trial showed a mean reduction of 29% in the YGTSS

Exposure & Response Prevention

  • Patients who have in a prolonged period of time with unpleasant premonitory sensations (exposure) and resisting the tic (response prevention), the patients may learn to tolerate the unpleasant sensation (habituation)
    • Habituation will lessen the urge or need to give into the tic, resulting in the reduction of tic behavior
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