Evidence-Based Reviews

Tics and tourette’s disorder: Which therapies, and when to use them

Current Psychiatry. 2003 October;2(10):45-56

First-line medications have changed; a new 6-step approach considers clinical experience and insights into tic causes and comorbidities.

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References

1. 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;42(1):98-105.

2. Jankovic J. Tourette’s syndrome. N Engl J Med 2001;345(16):1184-92.

3. Leckman JF, Goodman WK, Anderson GM, et al. CSF biogenic amines in obsessive-compulsive disorder and Tourette’s syndrome. Neuropsychopharmacology 1995;12:73-86.

4. Braun AR, Stoetter B, Randolph C, et al. The functional neuroanatomy of Tourette’s syndrome: An FDG-PET study: I. Regional changes in cerebral glucose metabolism differentiating patients and controls. Neuropsychopharmacology 1993;9:277-91.

5. Moriarty J, Campos D, Schmitz B, et al. Brain perfusion abnormalities in Gilles de la Tourette’s syndrome. Br J Psychiatry 1995;167:249-54.

6. Leckman JF. Cohen DJ (eds). Tourette’s syndrome. Tics, obsessions, compulsions: developmental psychopathology and clinical care. New York: John Wiley & Sons, 1999.

7. Budman C, Bruun R, Park K, Olson M. Rage attacks in children and adolescents with Tourette’s disorder: a pilot study. J Clin Psychiatry 1998;59(11):576-80.

8. Leckman JF, Riddle MA, Hardin MT, et al. The Yale Global Tic Severity Scale: Initial testing of a clinician-rated scale of tic severity. J Am Acad Child Adolesc Psychiatry 1989;28(4):566-73.

9. Spencer T, Biederman J, Harding M, et al. Disentangling the overlap between Tourette’s disorder and ADHD. J Child Psychol Psychiatry 1999;39:1037-44.

10. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry 1998;155:264-71.

11. Peterson AL, Azrin NH. An evaluation of behavioral treatments for Tourette syndrome. Behav Res Ther 1992;30(2):167-74.

12. Leckman JF, Hardin MT, Riddle MA, et al. Clonidine treatment of Gilles de la Tourette’s syndrome. Arch Gen Psychiatry 1991;48(4):324-8.

13. Dion Y, Annable L, Sandor P, Chouinard G. Risperidone in the treatment of Tourette syndrome: a double-blind, placebo-controlled trial. J Clin Psychopharmacology 2002;22(1):31-9.

14. Bruggeman R, van der Linden C, Buitelaar JK, et al. Risperidone versus pimozide in Tourette’s disorder: a comparative double-blind parallel-group study. J Clin Psychiatry 2001;62(1):50-6.

15. Onofrj M, Paci C, D’Andreamatteo G, Toma L. Olanzapine in severe Gilles de la Tourette syndrome: a 52-week double-blind, cross-over study vs. low-dose pimozide. J Neurol 2000;247:443-6.

16. Sallee FR, Kurlan R, Goetz, et al. Ziprasidone treatment of children and adolescents with Tourette’s syndrome: a pilot study. J Am Acad Child Adolesc Psychiatry 2000;39(3):292-9.

17. Parraga HC, Parraga MI, Woodward RL, Fenning PA. Quetiapine treatment of children with Tourette’s syndrome: report of two cases. J Child Adolesc Psychopharmacology 2001;11(2):187-91.

18. Sallee FR, Nesbitt L, Jackson C, et al. Relative efficacy of haloperidol and pimozide in children and adolescents with Tourette’s disorder. Am J Psychiatry 1997;154(8):1057-62.

19. Spencer T, Biederman J, Coffey B, et al. A double-blind comparison of desipramine and placebo in children and adolescents with chronic tic disorder and comorbid attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 2002;59(7):649-56.

20. Kurlan R. for the Tourette’s Syndrome Study Group. Treatment of ADHD in children with tics: A randomized controlled trial. Neurology 2002;58:527-36.

21. Spencer T, Biederman J, Kerman K, et al. Desipramine treatment of children with attention-deficit/hyperactivity disorder and tic disorder or Tourette’s syndrome. J Am Acad Child Adolesc Psychiatry 1993;32(2):354-60.

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When managing pediatric tics and Tourette’s disorder, we do not seek to eliminate tic symptoms. Instead—based on evidence and our experience—we use a six-step approach to increase tic control, decrease our patients’ embarrassment and discomfort, and help them function more normally.

Drug therapy is not appropriate for all children and adolescents with tic disorders. Mild transient tics and Tourette’s disorder usually do not require treatment, and medications should not be given to patients whose tics do not impair their quality of life. Treatment is warranted, however, when tics interfere with peer relations, social interactions, academic performance, or activities of daily living.

Standard treatment of pediatric tic disorders is changing. Instead of using typical antipsychotics, many experienced clinicians are using other medications that are safer and more effective, particularly for children and adolescents with psychiatric comorbidities such as attention-deficit/hyperactivity disorder (ADHD). In these patients, it is difficult to avoid drug interactions and exacerbation of non-targeted conditions when you attempt to control the tics.

Table 1

Diagnostic criteria for tic disorders

Shared characteristics
Tics defined as sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization Onset before age 18 Not caused by direct physiologic effects of a substance (such as stimulants) or general medical condition (such as Huntington’s disease or postviral encephalitis)
Transient tic disorder
Single or multiple motor and/or vocal tics occurring many times a day nearly every day for at least 4 weeks but no longer than 12 consecutive months Criteria for Tourette’s disorder or chronic motor or vocal tic disorder have never been met
Chronic motor or vocal tic disorder
Single or multiple motor or vocal tics, but not both, have been present at some time during the illness Tics occur many times a day nearly every day or intermittently for more than 1 year, without a tic-free period of more than 3 consecutive months Criteria for Tourette’s disorder or chronic motor or vocal tic disorder have never been met
Tourette’s disorder
Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently Tics occur many times a day (usually in bouts) nearly every day or intermittently for more than 1 year, without a tic-free period of more than 3 consecutive months
Source: Adapted from DSM-IV-TR

TICS’ FLUCTUATING COURSE

Tics and Tourette’s disorder are characterized by a fluctuating course. Tic activity tends to occur in bursts over hours to weeks, followed by relative quiescence—spontaneously varying from one extreme to the other. Tics:

are often preceded by mounting tension
occur most frequently without volition, although they can be consciously suppressed
are influenced by emotional state and tend to worsen during increased stress, excitement, or fatigue.

This variable natural history limits the value of uncontrolled studies, as symptom changes are not necessarily treatment-related.

DSM-IV-TR lists three types of childhood tic disorders (Table 1). Transient tics are seen in up to 10% of children, chronic tics are less common, and Tourette’s disorder has a community prevalence of 0.1 to 0.8%.¹ Tic disorders usually present by age 11² and are three times more common in boys than in girls. One-half of cases remit spontaneously by late adolescence or adulthood, with important treatment implications.²

Causes. Neurophysiologic studies suggest disinhibition and dysfunction of dopamine and related serotonergic pathways in the cortico-striatal-thalamic-cortical circuit.³ Corollary neuroimaging studies have found decreased metabolism and blood flow in the basal ganglia—specifically the caudate nucleus, thalamus, globus pallidus, and putamen—and increased activity in the frontotemporal cortex—specifically the prefrontal and supplementary motor areas.^4,5

Comorbidities. Tics and Tourette’s disorder rarely occur in isolation. The most common comorbidities and the frequencies with which they occur with tic disorders and Tourette’s disorder are:

ADHD (50% and 90%)⁶
obsessive-compulsive disorder (OCD)(11% and 80%)⁶
major depressive disorder (40% and 44%).^1,6

Additional comorbid problems include rage attacks, poor impulse control, and learning disorders. Many children with Tourette’s disorder display explosive rage.⁷

GUIDE TO WORKUP

During initial assessment, clearly delineate the onset, severity, complexity, and course of tics. Use empirically validated instruments—such as the Yale Global Tic Severity Scale⁸—at baseline and follow-up visits to monitor the natural history and clinical course, including treatment response. Determine predominant sources of distress and domains of impaired function.

Identify comorbid psychiatric illnesses (Box). Often, tics are not impairing⁹ and take on less clinical importance than the associated disorders. Prioritize target symptoms after considering the youth’s and family’s wishes. Follow a multidisciplinary approach, including behavioral, psychotherapeutic, and drug treatment as needed. Involve patients’ parents, schools, and teachers to help monitor functional impairment and treatment impact.

Use follow-up visits as needed to monitor treatment effectiveness. Follow-up frequency may decrease after tics are controlled to an acceptable level, although comorbid disorders may require continued attention.