The latest article in our Clinical Practice series, “Tourette’s Syndrome,” addresses the management of Tourette’s, with attention to cognitive behavioral therapy and pharmacotherapy; the potential role of deep-brain stimulation in severe cases is also discussed. The importance of treating common coexisting conditions is emphasized.
Tourette’s syndrome (sometimes called Tourette’s disorder) is a childhood-onset condition characterized by motor and vocal tics that are chronic (duration of >1 year).
• What types of tics are most typical of Tourette’s syndrome?
Motor tics include simple tics such as twitching, eye blinking, facial grimacing, or head jerking; slow twisting movements (dystonic tics); isometric contractions (tonic tics) such as tensing of the abdominal muscles; and more complicated, purposeful-looking movements (complex motor tics) such as touching or tapping. Vocal tics (also called phonic tics) include inarticulate noises such as throat clearing, sniffing, or coughing (simple vocal tics) and words or partial words (complex vocal tics). The most notorious tic of Tourette’s syndrome, obscene or insulting utterances (coprolalia), occurs in less than 50% of cases in reported series.
• What problems frequently coexist in patients with Tourette’s syndrome?
Tourette’s syndrome is now viewed as a neuropsychiatric 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) and with disturbances of attention that do not always meet the full criteria for attention deficit-hyperactivity disorder (ADHD).
Table 3. Tic-Suppressing Medications.
Morning Report Questions
Q: What behavioral treatments have been effective for patients with Tourette’s syndrome?
A: Clinical trials have shown that a form of cognitive behavioral therapy termed habit-reversal treatment is efficacious in suppressing tics. This form of therapy involves training patients to monitor their tics and premonitory sensations and to respond to them with a voluntary behavior that is physically incompatible with the tics.
Q: What pharmacologic therapy is effective for patients with disabling tics?
A: When tics are disabling, tic-suppressing therapy is indicated. The only medications for Tourette’s syndrome that have been approved by the Food and Drug Administration (FDA) are the classic neuroleptic antipsychotic agents haloperidol and pimozide, which block D2 dopamine receptors. Data from controlled clinical trials provide support for their efficacy. Randomized, controlled trials have also provided support for the efficacy of a newer atypical antipsychotic agent, risperidone, in suppressing tics, with a magnitude of benefit that is similar to that of the classic neuroleptics.