Parkinson's disease Center and Movement Disorders Clinic, Department of
Neurology, Baylor College of Medicine, 6550 Fannin Suite 1801, Houston, TX
77030, USA.
Proper education of the patient is the first step in the treatment of Tourette
syndrome (TS). Before deciding how to treat the patient, it is important to
decide whether to treat the TS-related symptoms. Counselling and behavioural
modification may be sufficient for those with mild symptoms. Medications,
however, may be considered when symptoms begin to interfere with peer
relationships, social interactions, academic or job performance, or with
activities of daily living. Therapy must be individualised and the most
troublesome symptoms should be targeted first. Antidopaminergic agents are
clearly the most effective drugs in the treatment of tics. Although
haloperidol and pimozide are the only drugs currently approved by the FDA for
the treatment of TS, other dopamine receptor-blocking drugs and tetrabenazine,
a dopamine depleting drug, as well as botulinum toxin injections, have been
used to treat tics associated with TS. Carefully designed, comparative,
longitudinal trials assessing the efficacy and adverse-effect profiles of
these drugs, including tardive dyskinesia, are lacking. Selective serotonin
reuptake inhibitors are recommended for the treatment of obsessive-compulsive
behaviour: a common comorbidity. Psychostimulants, such as methylphenidate,
are the treatment of choice for attention deficit hyperactivity disorder. Even
though these drugs may transiently increase tics, this does not necessarily
constitute a definite contraindication to the use of these drugs in patients
with TS. Here, existing and emerging medical treatments in patients with tics
and comorbid behavioural disorders associated with TS are reviewed.
Cincinnati Children's Hospital Medical Center, Division of Neurology, ML #2015,
3333 Burnet Avenue, Cincinnati, OH 45229, USA. d.gilbert@cchmc.org.
Tourette's syndrome is a childhood-onset neuropsychiatric disorder characterized
by multiple motor and vocal tics, frequently accompanied by symptoms of
obsessiveness and/or compulsiveness, anxiety, and behavioral impulsivity.
Treatment of Tourette's syndrome symptoms should be considered when symptoms
cause significant functional or social impairment or pain, as occurs with
self-injurious tics. Because comorbid psychiatric disorders, particularly
attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive
disorder often are present, clinicians must work with affected persons and
families and prioritize treatment targets based on the specific disorder-related
impairment. Treatment with alpha-2 adrenergic agonists may reduce tics and
improve ADHD symptoms. Effective treatment of ADHD, even with stimulant
medications, in most cases does not exacerbate tics. Treatment with selective
serotonin reuptake inhibitors may reduce obsessive-compulsive and anxiety
symptoms, secondarily reducing tics. Neuroleptics and atypical antipsychotics
may be used for severe tics, but the risk of neurologic side effects and weight
gain is significantly higher. Habit reversal treatment shows promise as a
nonpharmacologic intervention. Use of deep brain stimulation has produced
benefit in three severely affected adults but should still be considered
experimental.
