Evidence-Based Reviews

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

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

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.

22. Singer HS, Brown J, Quaskey S, et al. The treatment of attentiondeficit hyperactivity disorder in Tourette’s syndrome: A double-blind, placebo-controlled study with clonidine and desipramine. Pediatrics 1995;95(1):74-81.

Tricyclics’ potential toxicity in overdose and anticholinergic side effects require caution and may limit their use. However, they can be considered as adjuncts in treating chronic tic disorders, especially with comorbid ADHD. Serum levels and ECG monitoring every 3 to 6 months are required to rule out prolonged conduction times and tachycardia. Concurrent methylphenidate use may increase serum desipramine levels, and concurrent pimozide use may increase risk for arrhythmias.

OCD and anxiety disorders. Medically treating anxiety can help indirectly to manage tics, which are sensitive to stress.⁹ OCD comorbidity is especially common in youth with a family history of Tourette’s disorder.⁶ Screening for OCD is important, as its secretive symptoms frequently go unnoticed and its prognosis may be poorer with a concurrent tic disorder.

Standard treatment for pediatric OCD is cognitive-behavioral therapy, followed when needed by selective serotonin reuptake inhibitors (SSRIs), then clomipramine. These treatments are added to tic management, with attention to primary and comorbid symptoms. Anecdotal reports suggest that SSRIs occasionally exacerbate tics. Similarly, behavioral side effects are common in younger children treated with SSRIs and may aggravate ADHD symptoms.

Mood disorders. Except for tricyclics, antidepressants have been ineffective at reducing tics/Tourette’s disorder. Tricyclics, however, have not been proven effective in depressed youth, in part because of methodologic limitations in controlled trials. Even so, tricyclics may help some children with tics and major depressive disorder. SSRIs combined with usual tic treatment may also be tried, with monitoring for tic worsening.⁹ To control rage attacks, a trial of mood stabilizers or atypical antipsychotics may be combined with standard tic medications.

Related resources

Leckman JF, Cohen DJ (ed). Tourette’s syndrome. Tics, obsessions, compulsions: developmental psychopathology and clinical care. New York: John Wiley & Sons, 1999.
Jankovic J. Tourette’s syndrome. N Engl J Med 2001;345(16):1184-92.
Martin A, Scahill L, Charney DS, Leckman JF (ed). Pediatric psychopharmacology: principles and practice. New York: Oxford University Press, 2003.
Tourette Syndrome Association. www.tsa-usa.org

Drug brand names

Aripiprazole • Abilify
Atomoxetine • Strattera
Desipramine • Norpramin
Clomipramine • Anafranil
Clonazepam • Klonopin
Clonidine • Catapres
Clozapine • Clozaril
Desipramine • Norpramin
Fluphenazine • Permitil, Prolixin
Guanfacine • Tenex
Haldoperidol • Haldol
Imipramine • Tofranil
Lorazepam • Ativan
Molindone • Moban
Nortriptyline • Pamelor
Olanzapine • Zyprexa
Pimozide • Orap
Quetiapine • Seroquel
Risperidone • Risperdal
Thioridazine • Mellaril
Thiothixine • Navane
Trifluoperazine • Stelazine
Ziprasidone • Geodon

Disclosure

Dr. Stewart and Loren Gianini report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Geller receives grant/research support from Eli Lilly and Co. and Forest Laboratories Inc., is a consultant to GlaxoSmithKline, and is a speaker for Eli Lilly and Co., Wyeth Pharmaceuticals, Novartis Pharmaceuticals Corp., and Shire Pharmaceuticals Group.

Dr. Spencer receives research/grant support from and is a speaker or consultant for Abbott Laboratories, Ortho-McNeil Pharmaceutical Inc., GlaxoSmithKline, Eli Lilly and Co., Novartis Pharmaceuticals Corp., Pfizer Inc., Shire Pharmaceuticals Group, and Wyeth Pharmaceuticals.