Treatment of Tourette syndrome

Tourette syndrome (also Tourette's syndrome or TS) is an inherited neurological disorder with onset in childhood, characterized by the presence of motor and phonic tics. Treatment of Tourette syndrome has the goal of managing symptoms to achieve optimum functioning, rather than eliminating symptoms; not all persons with Tourette's require treatment, and there is no cure or universally effective medication.Schapiro NA. "Dude, you don't have Tourette's": Tourette's syndrome, beyond the tics. "Pediatr Nurs." 2002 May-Jun;28(3):243-6, 249-53. PMID 12087644] Zinner SH. Tourette disorder. "Pediatr Rev". 2000;21(11):372-383. PMID 11077021] National Institute of Neurological Disorders and Stroke/National Institutes of Health (NINDS/NIH). [http://www.ninds.nih.gov/disorders/tourette/detail_tourette.htm Tourette Syndrome Fact Sheet] . 2007-02-14. Retrieved on May 14 2007.] Explanation and reassurance alone are often sufficient treatment; education is an important part of any treatment plan.Peterson BS, Cohen DJ. The Treatment of Tourette's Syndrome: Multimodal, Developmental Intervention. "J Clin Psychiatry." 1998;59 Suppl 1:62–72; discussion 73–4. PMID 9448671 [http://web.archive.org/web/19980525041730/http://www.psychiatrist.com/psychosis/worldwide/current/tourettes.htm Full text] , archived May 25 1998. "Because of the understanding and hope that it provides, education is also the single most important treatment modality that we have in TS."]

Tourette syndrome patients may exhibit symptoms of other comorbid conditions along with their motor and phonic tics. Associated conditions include attention-deficit hyperactivity disorder (ADD or ADHD), obsessive-compulsive disorder (OCD), learning disabilities and sleep disorders. Patients who have ADHD along with Tourette's may also have problems with disruptive behaviors, overall functioning, and cognitive function. Co-occurring OCD can also be a source of impairment, necessitating treatment. Not all persons with tics will also have other conditions and not all persons with tics require treatment, but when comorbid disorders are present, they often require treatment.

Stimulants (like Adderall and Ritalin) are underused in the treatment of ADHD when tics are also present because of unfounded fears that they increase tics. Experimental treatments like deep brain stimulation, nicotine, marijuana and complementary and alternative medicine approaches have widespread appeal but unproven safety and efficacy.

Treatment priority

Treatment of Tourette syndrome can be divided into treatment of tics, and treatment of co-occurring conditions, which, when present, are often a larger source of functional impairment than the tics themselves.Scahill L, Erenberg G, Berlin CM Jr, Budman C, Coffey BJ, Jankovic J, Kiessling L, King RA, Kurlan R, Lang A, Mink J, Murphy T, Zinner S, Walkup J; Tourette Syndrome Association Medical Advisory Board: Practice Committee. Contemporary assessment and pharmacotherapy of Tourette syndrome. "NeuroRx." 2006 Apr;3(2):192–206. PMID 16554257]

There is no cure for Tourette's and no medication which works universally for all individuals without significant adverse effects; knowledge and understanding are the best treatments available for tics.Peterson BS, Cohen DJ. The Treatment of Tourette's Syndrome: Multimodal, Developmental Intervention. Presented at a closed symposium held in New Orleans, Louisiana on April 12, 1996. No longer online at psychiatrist.com/psychosis/worldwide/current/tourettes.htm "Because of the understanding and hope that it provides, education is also the single most important treatment modality that we have in TS."] Management of the symptoms of Tourette's may include pharmacological, behavioral and psychological therapies. While pharmacological treatment is reserved for more severe symptoms, other types of treatments may help avoid or improve symptoms of depression or social isolation, and improve supportive family functioning. Educating the patient, family, and surrounding community (school, church, friends, etc.) is a key part of treatment.

The majority of people with TS require no medication, but medication is available to help when symptoms interfere with functioning. Because children with tics often present to physicians when their tics are at their highest severity, and because of the waxing and waning nature of tics, medication is not usually started immediately or changed often. Frequently, the tics subside with understanding of the condition and a supportive environment. When medication is necessary, pharmaceutical intervention should be targeted at the most impairing symptoms, taking into account co-occurring conditions such as ADHD or OCD, which when present, may warrant treatment even when tics are mild.

The classes of medication with the most proven efficacy in treating tics—typical and atypical neuroleptics including risperidone (trade name [Medication trade names may differ between countries. In general, this article uses North American trade names.] Risperdal), ziprasidone (Geodon), haloperidol (Haldol), pimozide (Orap) and fluphenazine (Prolixin)—can have long-term and short-term adverse effects.Scahill L, Erenberg G, Berlin CM Jr, Budman C, Coffey BJ, Jankovic J, Kiessling L, King RA, Kurlan R, Lang A, Mink J, Murphy T, Zinner S, Walkup J; Tourette Syndrome Association Medical Advisory Board: Practice Committee. Contemporary assessment and pharmacotherapy of Tourette syndrome. "NeuroRx." 2006 Apr;3(2):192–206. PMID 16554257] The antihypertensive agents, clonidine (Catapres) and guanfacine (Tenex), are also used to treat tics; studies show variable efficacy, but a lower side effect profile than the neuroleptics.Schapiro NA. "Dude, you don't have Tourette's:" Tourette's syndrome, beyond the tics. "Pediatr Nurs." 2002 May-Jun;28(3):243-6, 249-53. PMID 12087644] Stimulants and other medications may be useful in treating ADHD when it co-occurs with tic disorders. Drugs from several other classes of medications can be used when stimulant trials fail, including guanfacine (Tenex), atomoxetine (Strattera) and tricyclics. Clomipramine (Anafranil), a tricyclic antidepressant, and SSRIs—a class of antidepressants including fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox)—may be prescribed when a Tourette's patient also has symptoms of obsessive–compulsive disorder.

Cognitive Behavioral Therapy (CBT) is a useful treatment when OCD is present, [Coffey BJ, Shechter RL. Treatment of co-morbid obsessive compulsive disorder, mood, and anxiety disorders. "Adv Neurol." 2006;99:208–21. PMID 16536368] and there is increasing evidence supporting the use of habit reversal in the treatment of tics. [Himle MB, Woods DW, Piacentini JC, Walkup JT. Brief review of habit reversal training for tourette syndrome. "J Child Neurol." 2006 Aug;21(8):719–25. PMID 16970874] Relaxation techniques, such as exercise, yoga or meditation, may be useful in relieving stress that may aggravate tics, but the majority of behavioral interventions (such as relaxation training and biofeedback, with the exception of habit reversal) have not been systematically evaluated and are not proven therapies for Tourette's. [Woods DW, Himle MB, Conelea CA. Behavior therapy: other interventions for tic disorders. "Adv Neurol." 2006;99:234–40. PMID 16536371]

Treatment of tics

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Newer neuroleptics, the atypical neuroleptics, are an alternative to the traditional medications used for treating tics. These medications have more selective dopamine blocking effects, or block serotonin with some blocking of dopamine. The medications in this class used to treat tics include risperidone (brand name Risperdal), olanzapine (brand name Zyprexa), ziprasidone (brand name Geodon), quetiapine (brand name Seroquel), clozapine (brand name Clozaril), tiapride, and sulpiride. They seem to have lower risks of neurological side effects (such as tardive dyskinesia) when used short-term, but longer trials are needed to confirm this. Some of the side effects associated with these medications are insomnia, weight gain, and school phobia. Abnormalities in metabolism, cardiac conduction times, and increased risk of diabetes are concerns with these medications. There is good empirical support for the use of risperidone, and less support for the others.

The α₂-adrenergic receptor agonists (antihypertensive agents) show some efficacy in reducing tics, as well as other comorbid features of some people with Tourette's. Originally developed to treat high blood pressure, these medications are a safer alternative to neuroleptic medications for the people with TS that respond to them. This class of medication is often the first tried for tics, as the antihypertensives have a lower side effect profile than some of the medications which more proven efficacy. The evidence for their safety and efficacy is not as strong as the evidence for some of the standard and atypical neuroleptics, but there is fair supportive evidence for their use, nonetheless. [Leckman JF, Hardin MT, Riddle MA, "et al." Clonidine treatment of Gilles de la Tourette's syndrome. "Arch Gen Psychiatry". 1991 Apr;48(4):324-8. PMID 2009034 ] This class of medication takes about six weeks to begin to work on tics, so sustained trials are warranted. Because of the blood pressure effects, antihypertensive agents should not be discontinued suddenly. Clonidine (brand name Catapres) works on tics for about half of people with TS. [Leckman JF, Cohen DJ, Detlor J, "et al." Clonidine in the treatment of Tourette syndrome: a review of data. "Adv Neurol". 1982;35:391-401. PMID 6756089] [Leckman JF, Detlor J, Harcherik DF, "et al." Short- and long-term treatment of Tourette's syndrome with clonidine: a clinical perspective. "Neurology". 1985 Mar;35(3):343-51. PMID 3883235] Maximal benefit may not be achieved for 4–6 months. A small number of patients may worsen on clonidine.Robertson MM. Tourette syndrome, associated conditions and the complexities of treatment. "Brain". 2000;123 Pt 3:425-462. PMID 10686169] Guanfacine (brand name Tenex) is another antihypertensive that is used in treating TS. Side effects can include sedation, dry mouth, fatigue, headaches and dizziness. Sedation can be problematic when treatment is first initiated, but may wear off as the patient adjusts to the medication.

Other medications that can be used to treat tics include pergolide (brand name Permax), botulinum toxin, and with less empirical support for efficacy, tetrabenazine and baclofen.

Treatment of ADHD in the presence of tic disorders

Patients with Tourette's who are referred to specialty clinics have a high rate of comorbid attention-deficit hyperactivity disorder (ADHD), so the treatment of ADHD co-occurring with tics is often part of the clinical treatment of Tourette's. Patients who have ADHD along with Tourette's may also have problems with disruptive behaviors, overall functioning, and cognitive function, accounted for by the comorbid ADHD, highlighting the importance of identifying and treating other conditions when present. [Sukhodolsky DG, Scahill L, Zhang H, "et al." Disruptive behavior in children with Tourette's syndrome: association with ADHD comorbidity, tic severity, and functional impairment. "J Am Acad Child Adolesc Psychiatry". 2003 Jan;42(1):98-105. PMID 12500082
* Hoekstra PJ, Steenhuis MP, Troost PW, "et al." Relative contribution of attention-deficit hyperactivity disorder, obsessive-compulsive disorder, and tic severity to social and behavioral problems in tic disorders. "J Dev Behav Pediatr". 2004 Aug;25(4):272-9. PMID 15308928
* Carter AS, O'Donnell DA, Schultz RT, "et al." Social and emotional adjustment in children affected with Gilles de la Tourette's syndrome: associations with ADHD and family functioning. Attention Deficit Hyperactivity Disorder. "J Child Psychol Psychiatry". 2000 Feb;41(2):215-23. PMID 10750547
* Spencer T, Biederman J, Harding M, "et al." Disentangling the overlap between Tourette's disorder and ADHD. "J Child Psychol Psychiatry". 1998 Oct;39(7):1037-44. PMID 9804036]

The treatment of ADHD in the presence of tic disorders has long been a controversial topic. Past medical practice held that stimulants (such as Ritalin) could not be used in the presence of tics, due to concern that their use might worsen tics;Freeman, RD. [http://www.tourette-confusion.blogspot.com/ Tourette's Syndrome: minimizing confusion] . Retrieved on 8 February 2006.] however, multiple lines of research have shown that stimulants can be cautiously used in the presence of tic disorders. [Palumbo D, Spencer T, Lynch J, "et al." Emergence of tics in children with ADHD: impact of once-daily OROS methylphenidate therapy. "J Child Adolesc Psychopharmacol". 2004 Summer;14(2):185-94. PMID 15319016
* Kurlan R. Tourette's syndrome: are stimulants safe? "Curr Neurol Neurosci Rep". 2003 Jul;3(4):285-8. PMID 12930697
* Law SF, Schachar RJ. Do typical clinical doses of methylphenidate cause tics in children treated for attention-deficit hyperactivity disorder? "J Am Acad Child Adolesc Psychiatry". 1999 Aug;38(8):944-51. PMID 10434485
* Nolan EE, Gadow KD, Sprafkin J. Stimulant medication withdrawal during long-term therapy in children with comorbid attention-deficit hyperactivity disorder and chronic multiple tic disorder. "Pediatrics". 1999 Apr;103 (4 Pt 1):730-7. PMID 10103294] Several studies have shown that stimulants do not exacerbate tics any more than placebo does, and suggest that stimulants may even reduce tic severity. [Tourette's Syndrome Study Group. Treatment of ADHD in children with tics: a randomized controlled trial. "Neurology". 2002 Feb 26;58(4):527-36. PMID 11865128] Controversy remains, and the PDR continues to carry a warning that stimulants should not be used in the presence of tic disorders, so physicians may be reluctant to use them. Others are comfortable using them and even advocate for a stimulant trial when ADHD co-occurs with tics, because the symptoms of ADHD can be more impairing than tics.

The stimulants are the first line of treatment for ADHD, with proven efficacy, but they do fail in up to 20% of cases, even in patients without tic disorders. Current prescribed stimulant medications include: methylphenidate (brand names Ritalin, Metadate, Concerta), dextroamphetamine (Dexedrine), and mixed amphetamine salts (Adderall). Other medications can be used when stimulants are not an option. These include the alpha-2 agonists (clonidine and guanfacine), tricyclic antidepressants (desipramine and nortriptyline), and newer antidepressants (bupropion, venlafaxine and atomoxetine). A retrospective case series published in 1993 suggested that treatment with bupropion (trade name Wellbutrin) can worsen tics, [Spencer T, Biederman J, Steingard R, Wilens T. Bupropion exacerbates tics in children with attention-deficit hyperactivity disorder and Tourette's syndrome. "J Am Acad Child Adolesc Psychiatry". 1993 Jan;32(1):211–4. PMID 8428875] but there is no data from placebo-controlled trials to support this. [Poncin Y, Sukhodolsky DG, McGuire J, Scahill L. Drug and non-drug treatments of children with ADHD and tic disorders. "Eur Child Adolesc Psychiatry". 2007 Jul 31;16 Suppl 9:78–88. doi|10.1007/s00787-007-1010-8] There is good empirical support for the use of desipramine, bupropion and atomoxetine (brand name Strattera). Atomoxetine is the only non-controlled Food and Drug Administration (FDA) approved drug for the treatment of ADHD, but is less effective than stimulants for ADHD, is associated with individual cases of liver damage, carries an FDA black box warning regarding suicidal ideation, and controlled studies show increases in heart rate, decreases of body weight, decreased appetite and treatment-emergent nausea. [Allen AJ, Kurlan RM, Gilbert DL, "et al." Atomoxetine treatment in children and adolescents with ADHD and comorbid tic disorders. "Neurology". 2005 Dec 27;65(12):1941-9. PMID 16380617]

Experimental treatments

Complementary and alternative medicine approaches, such as dietary modification, allergy testing and allergen control, and neurofeedback, have popular appeal, but no role has been proven for any of these in the treatment of Tourette syndrome.Zinner SH. Tourette syndrome—much more than tics. "Contemporary Pediatrics". Aug 2004;21(8):22-49. [http://www.tsa-usa.org/Medical/images/cntped0804_022-036T1R2.pdf Part 1 PDF] [http://www.tsa-usa.org/Medical/images/cntped0804_038-049T2R1.pdf Part 2 PDF] ]

Nicotine showed preliminary promise in case studies, but these effects were not reproduced in well-controlled trials several years later.Swerdlow, NR. Tourette Syndrome: Current Controversies and the Battlefield Landscape. "Curr Neurol Neurosci Rep". 2005, 5:329-331. PMID 16131414] Studies of nicotine derivatives (mecamylamine, inversine) also showed that they were not effective as a single therapy for the symptoms of Tourette's. [Silver AA, Shytle RD, Sheehan KH, "et al." Multicenter, double-blind, placebo-controlled study of mecamylamine monotherapy for Tourette's disorder. "J Am Acad Child Adolesc Psychiatry". 2001 Sep;40(9):1103-10. PMID 11556635]

Case reports found that marijuana helped reduce tics, but validation of these results requires longer, controlled studies on larger samples. [Sandyk R, Awerbuch G. Marijuana and Tourette's syndrome. "J Clin Psychopharmacol". 1988 Dec;8(6):444-5. PMID 3235704] [Muller-Vahl KR, Kolbe H, Dengler R. [Gilles de la Tourette syndrome. Effect of nicotine, alcohol and marihuana on clinical symptoms] "Nervenarzt". 1997 Dec;68(12):985-9. German. PMID 9465342] Controlled research on treating Tourette's with a synthetic version of tetrahydrocannabinol, the main psychoactive chemical found in cannabis (brand name Marinol), showed the patients taking Marinol had a significant reduction in tic severity without serious adverse effects, and more significant reduction in tic severity was reported with longer treatment. [Muller-Vahl KR, Schneider U, Prevedel H, "et al." Delta 9-tetrahydrocannabinol (THC) is effective in the treatment of tics in Tourette syndrome: a 6-week randomized trial. "J Clin Psychiatry". 2003 Apr;64(4):459-65. PMID 12716250] The researchers reported a trend towards improvement in cognitive functioning in patients taking Marinol, before and after treatment. [Muller-Vahl KR, Prevedel H, Theloe K, "et al." Treatment of Tourette syndrome with delta-9-tetrahydrocannabinol (delta 9-THC): no influence on neuropsychological performance. "Neuropsychopharmacology". 2003 Feb;28(2):384-8. PMID 12589392]

Deep brain stimulation has been used in treating a few patients with severe Tourette's, but is regarded as an experimental and dangerous procedure that is unlikely to become widespread. [Tourette Syndrome Association. [http://web.archive.org/web/20050226093006/http://www.tsa-usa.org/news/DBS-Statement.htm Statement: Deep Brain Stimulation and Tourette Syndrome.] Retrieved on 26 February 2005.] The procedure is well tolerated, but complications include "short battery life, abrupt symptom worsening upon cessation of stimulation, hypomanic or manic conversion, and the significant time and effort involved in optimizing stimulation parameters".Malone DA Jr, Pandya MM. Behavioral neurosurgery. "Adv Neurol." 2006;99:241-7. PMID 16536372] There are currently five reports in patients with TS; all experienced reduction in tics and the disappearance of obsessive-compulsive behaviors. "Only patients with severe, debilitating, and treatment-refractory illness should be considered; while those with severe personality disorders and substance abuse problems should be excluded."

See also

Notes

External links

*NINDS. [http://www.ninds.nih.gov/news_and_events/news_articles/news_article_adhd.htm Methylphenidate and Clonidine Help Children With ADHD and Tics.] (April 2 2002)
*Packer, Leslie. [http://www.tourettesyndrome.net/tourette_treatment.htm Treatment of Tics and Tourette's syndrome.]