Tourette’s syndrome is a childhood-onset condition that is diagnosed when motor and vocal tics have been present for at least 1 year. The syndrome is now viewed as a neuropsychiatry spectrum disorder in which tics are commonly associated with obsessive-compulsive symptoms that do not always meet the full diagnostic criteria for obsessive-compulsive disorder (OCD). Tourette’s has also been associated with disturbances of attention that do not always meet the full criteria for ADHD. The combination of tics, OCD, and ADHD—often called the Tourette’s syndrome triad—can be challenging to diagnose and treat.
In the December 9, 2010 New England Journal of Medicine, I had a review published that discussed strategies and guidelines on diagnosing and treating Tourette’s syndrome in clinical practice settings. Tic suppression often occurs in physicians’ offices, so the most opportune time to look for tics is when patients are entering or leaving the examination room. Coexisting psychiatric conditions can be evaluated with clinical rating scales too.
Management Strategies
Virtually any movement or sound that the body is capable of making can be a manifestation of a tic. The most notorious tics of Tourette’s syndrome include obscene or insulting utterances (coprolalia), but these occur in less than half of all cases. When tics are mild and not disabling, education about Tourette’s and supportive counseling to strengthen self-confidence and self-esteem usually suffice. When tics are disabling, they cause social embarrassment or self-injury for which tic-suppressing therapy is indicated. Treatment options include habit-reversal treatment, a form of cognitive behavioral therapy, or pharmacotherapy.
“The most opportune time to look for tics is when patients are entering or leaving the examination room.”
Neuroleptic antipsychotic agents that block D2 dopamine receptors have been approved by the FDA for Tourette’s syndrome. Risperidone, a newer atypical antipsychotic agent, appears to suppress tics with a magnitude of benefit similar to that of neuroleptic antipsychotic agents, but more research is needed about the most appropriate medications, because antipsychotic agents are associated with sedation, depression, increased appetite, and parkinsonism. The atypical antipsychotics have fewer motor complications but often induce weight gain and glucose intolerance. Because of these adverse effects, other medications, such as the a2-adrenergic drugs may be effective, depending on the patient’s characteristics. Other possible approaches include combination pharmacotherapy, botulinum toxin, or deep brain stimulation. Appropriate treatment of coexisting conditions is also recommended.
Follow Guideline Recommendations
The Practice Parameter Group of the Tourette Syndrome Association (www.tsa-usa.org) has published recommendations for the evaluation, diagnosis, and treatment of Tourette’s syndrome and associated psychiatric conditions. They recommend that guanfacine or clonidine be considered first-line medications for moderate or more severe tics. Botulinum toxin may be considered in patients with a single interfering tic. More potent medications may be considered for tics with an inadequate response to the a2-adrenergic drugs.
Many patients with Tourette’s require treatment for both tics and coexisting conditions. As a result, combination therapy with tic-suppressing, anti-OCD, and anti-ADHD medications is commonly used. However, no formal assessments of such combination therapies have been reported. As more systematic research explores these combinations, there is hope that clinicians will be armed with better data to optimize their patient management approaches in the future. Ultimately, the goal is to reduce symptoms for this often life-long condition.
JonN