IACAPAP Textbook of Child and Adolescent Mental Health

OTHER DISORDERS

Chapter

H.2

TIC DISORDERS
Hannah Metzger, Sina Wanderer & Veit Roessner

Hannah Metzger MSc
Clinical child psychologist,
Department of Child andAdolescent Psychiatry/
Psychotherapy, Technische
Universität Dresden, Germany
Conflict of interest: none
declaredSina Wanderer Dipl-Psych
Department of Child andAdolescent Psychiatry/
Psychotherapy, Technische
Universität Dresden, Germany
Conflict of interest: none
declared

Veit Roessner MD
Samuel Johnson, one of
the most influential English
literary figures, particularly
because of his “Dictionaryof the English Language”
published in 1755, appears
to have suffered from
Tourette’s disorder.

Professor of child andadolescent psychiatry,
Department of Child andAdolescent Psychiatry/
Psychotherapy, Technische
Universität Dresden, Germany
Conflict of interest: none
declared

Portrait by Joshua Reynolds

This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Metzger H, Wanderer S, Veit Roessner V. Tic disorders. In Rey JM (ed), IACAPAP e-Textbook of Child andAdolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

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IACAPAP Textbook of Child and Adolescent Mental HealthT

ics may range from a discrete, hardly noticeable flinching of the eye toa painful, socially incapacitating und subjectively shameful phenomena
involving several muscle groups. Those afflicted by tics, as well as theirfamily, may experience substantial suffering due to the symptoms, be it throughbullying or to inappropriate response by caregivers resulting in a dysfunctional
parent-child relationship. People in the extended environment may also react withirritation, for instance where vocal tics occur in inappropriate settings, such as
the cinema or the classroom. On the other hand, some of the people afflictedsuccessfully develop strategies to control their tics and learn to live and cope with
them.
Classification usually follows the criteria of the International Classificationof Diseases (ICD-10; World Health Organisation, 1996) or the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric
Association,1994). Tic disorders are best classified among the neuropsychiatricdisorders. Table H.2.1 shows the classification of tic disorders.
Whether a transient or a chronic tic disorder is present depends on the
duration of symptoms: in the case of a transient tic disorder, symptoms last lessthan 12 months. Transient tic disorders mostly occur in school age children andusually do not require specific treatment.
Diagnosis of Gilles-de-la-Tourette syndrome (or simply Tourette syndromeor disorder) is warranted in cases where several motor tics and at least one vocal tic
are present at the same time or have been present in the past. Motor and vocal tics
do not have to be present at the same time but should have occurred almost every
day over one year at least to warrant the diagnosis. The onset of Tourette syndromeis generally before the age of 18; it rarely occurs for the first time in adulthood.

EPIDEMIOLOGY
It is estimated that 4% to12 % of all children suffer from tics at some time
during their development. Approximately 3%-4% are afflicted by a chronictic disorder and 1% with Tourette’s syndrome (Rothenberger et al, 2007).
Children and adolescents are 10 times more likely to suffer from tics than adults(Kerbeshian & Burd 1992). This may be due to the high spontaneous remission
rate in younger patients. Boys are afflicted three to four times more often than
girls (Freeman, 2007). A familial predisposition has been established (O’Rourke
et al, 2011).

Georges Albert Édouard
Brutus Gilles de la Tourette(1857-1904), French
neurologist, described thesymptoms of the syndromethat bears his name in ninepatients in 1884, which hetermed “maladie des tics".
Gilles de la Tourette had acolourful and eventful life.
He was shot in the head in
his consulting rooms by aparanoid young woman who
had been a patient at theSalpêtrière Hospital claiming
she had been hypnotised byhim against her will causing
her to lose her sanity.
The trial sparked intense
public debate over whether
hypnosis could be used toinduce criminal behavior
in otherwise law-abiding
citizens.
He died in a psychiatrichospital in Lausanne,
Switzerland, where he had
been interned probably
because of a bipolar illness
and syphilis.

Table H.2.1 Classification of tic disorders according to ICD-10 and
DSM-IVICD- 10

DSM - IV

F95.0 Transient tic disorder

307.21 Transient tic disorder

F95.1 Chronic motor or vocal tic disorder

307.22 Chronic motor or vocal tic disorder

F95.2 Combined vocal and multiple motor
tic disorder (Gilles-de-la-Tourette
syndrome)

307.23 Tourette's disorder

F95.8 Other tic disorder

307.20 Tic disorder NOS (not otherwise
specified)

F95.9 Unspecified

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Cultural differences
The prevalence of Tourette syndrome is about 1% worldwide (Robertson etal, 2009). However, Tourette syndrome is less likely to occur in some countries.
Differences in prevalence across various countries seem partly to reflect the factthat not all follow the same classification system. China, for example, has reported
slightly lower prevalence rates; rates appear to be lower among African Americans
in the US and occurrence is extremely rare in Sub-Saharan black Africans. Possible
reasons for these findings include the implementation of different diagnostic
systems, other medical priorities with less likelihood to seek treatment, ethnicand epigenetic differences, genetic and allelic differences in different races andthe presence of a mixture of races (Robertson, 2008). By contrast, a cross-culturalreview by Staley et al (1997) concluded that demography, family history, clinicalfeatures, associated conditions, comorbidity and treatment outcome were basicallythe same across cultures.

Tic
Sudden, rapid, recurrent,
nonrhythmic motor
movement or vocalization.

Age at onset and course
Tics generally occur for the first time between the ages of two and 15 years.
However, the peak age of onset is between six and eight years. Typically, the firstsymptom is a simple motor tic in the face, such as eye blinking or grimacing. With
time, they spread to shoulders, extremities and torso. Often vocal tics appear two
to four years after the start of the motor tics (Leckman et al, 1998).
In most cases tics fluctuate in their location, complexity, type, intensity andfrequency. This can be confusing and frustrating for parents of children afflicted bytics. Fluctuations often occur at irregular intervals, approximately every six to 12
weeks, without any apparent reason (Roessner et al, 2004). This changing course
is one of the main distinguishing features when differentiating between Tourette
syndrome and the abnormal movements found in conjunction with other illnesses,
such as dystonia or chorea, which typically do not change or show less accentuatedfluctuations.

Figure H.2.1 Evaluation of treatment efficacy in Tourette’s syndrome in light of the natural
waxing and waning

At date 1 (in which a reduction in tics naturally occurs) a therapeutic intervention is followed by a reduction in tics
irrespective of the intervention’s potential to increase or not to have an effect on tics. The reduction could be falsely
attributed to the intervention when in fact was the result of the tics natural waxing and waning. A therapeutic intervention
at date 2 could be followed by an increase in tics despite its potential to reduce tics. The effect of the therapeuticintervention might attenuate the natural waxing of the tics but is biased by the spontaneous increase. This means thata meaningful appraisal of treatment efficacy in Tourette’s disorder can only be ascertained in most cases after a longobservation period. Source: Roessner et al (2011). Reproduced with permission.

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Usually there is a worsening of symptoms during adolescence. As children
progresses into young adulthood, tics often go into remission (Sandor et al, 1990).
As a result, children and adolescents are 10 times more likely to be affected thanadults.
With increasing age, tic-afflicted patients also gain better control overtheir tics and are often able to suppress them for minutes or up to several hours.
However, after a period of suppression, patients often feel compelled to exhibit
their tics with heightened intensity (Banaschewski et al, 2003). For this reason
some children may be able to suppress their tics over the course of the school day
but, as soon as the child arrives at home, tics reappear with more intensity and the
feelings of heightened tension generated by the suppression of tics will temporarily
fade.
The severity of the tic disorder during childhood only has a limited predictive
value concerning the illness in adulthood. A poor prognosis is usually associatedwith:• Familial history• Existence of vocal or complex tics
• Comorbid hyperkinetic disorder• Obsessive-compulsive symptoms• Aggressive behavior against self or others.
Spontaneous remission of chronic simple or multiple tics occurs in 50% to70 % of cases and 3% to 40% for Tourette syndrome (Erenberg et al,1987).

ETIOLOGY AND RISK FACTORS

Click on the picture to view avideo clip showing a varietyof tics (3:13)

Although the cause of primary tic disorders has not been conclusively
determined, it is widely assumed to be the result of an interaction of genetic,
neurobiological and psychological factors as well as environmental influences.
A dysregulation within cortico-striato-thalamo-cortical circuits with deviations
within the dopaminergic and serotonergic systems is believed to be responsible
for the occurrence of tics. It seems that overactivity of the dopaminergic system inthe basal ganglia leads to deficient subcortical inhibition and impaired automatic
control of movement, which then clinically presents itself as motor or vocal tics
(Leckman et al 1997; Singer, 2011).
A familial predisposition is as a risk factor. Heritability has been estimatedto be around 50 % (Singer & Walkup, 1991). Various prenatal, perinatal andpostnatal factors are considered possible factors that increase the risk. They include
premature birth, perinatal hypoxia, low birth weight as well as excessive nicotine
and caffeine consumption by mother during pregnancy. On rare occasions tics
may develop as secondary symptom of tumors, poisoning, infection, head trauma
or vascular disease (Burd et al, 1999; Mathews et al, 2006) .
Medical imaging techniques have determined that, on a neuroanatomicallevel, patients with tics show a reduced volume of the basal ganglia as well as the
corpus callosum, but heterogeneity of study samples in terms of several confounders(e.g., long-term use of medication, tic performance and suppression over years)
prevents firm conclusions. Furthermore, deviation of glucose metabolism inthe basal ganglia, prefrontal and the somatic sensorimotor cortex, insula and

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IACAPAP Textbook of Child and Adolescent Mental Healthtemporal lobe has become apparent. Apart from dopaminergic overactivity, otherneurotransmitters implicated include dysfunctions within the serotonergic andnoradrenergic systems.
In terms of psychosocial factors, poor child rearing techniques have been
ruled out as risk factor. However, environmental influences, first and foremost
psychosocial stress, undoubtedly modulate tic severity. Experiences that cause fear,
emotional trauma and social pressure generally result in an exacerbation of tics.

TICS
Tics are sudden, abrupt, fast movements comprising various muscle groups,
with or without vocal utterances, which occur involuntarily. Tics are brief but
repetitive – though not rhythmic – and usually appear in short bursts or even series.
They may be classified according to the degree of complexity (simple, complex) as
well as their quality (motor, vocal) (Rothenberger et al, 2007).
Motor tics range from simple, sudden movements such as eye blinking
or grimacing, to complex behavioral patterns, for example crouching down or
hopping. In extreme cases, complex motor tics may present themselves as obscene
gestures (referred to as copropraxia; e.g., pulling trousers down) or even have anelement of self-harm (e.g., hitting oneself in the head). In some cases the afflictedperson is compelled to repeat or imitate a movement observed in another person(echopraxia).
Vocal or phonic tics are involuntary utterances of sounds, noises, sentences orwords. A simple vocal tic may be a slight coughing, clearing of throat, wheezing,squeaking or loud shouting. More complex vocal tics involve syllables, words orsentences. Coprolalia is the utterance of obscene or aggressive words or sentences.
Coprolalia occurs seldom, in less than 20% of persons affected by Tourette disorder(Rothenberger et al, 2007). In other cases sufferers feel compelled to repeat theirown previously spoken words (palilalia – it is called echolalia if they repeat words
previously spoken by someone else).
By the age of 10 or 11 years, children begin to report a premonitory urge.
This can be any kind of sensation, typically a tickling, itching or prickling feeling,in the area of the muscle groups involved, announcing the imminent occurrenceof a tic (Steinberg et al, 2010).
Table H.2.2

Common motor and vocal tics.
Motor Tics

•
•
•
•
•
•
•
•
•

Eye blinking
Rolling of eyes
Grimacing
Shaking of headTwitching of shoulders
Twitching of torso and pelvis
Twitching of abdomen
Movements of the hands and arms
Movements of the feet and legs

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Vocal Tics
•
•
•
•
•
•
•
•
•

Coughing
Throat clearing
Sniffing
Whistling
Grunting
Animal sounds
Uttering of syllables
Uttering of words
Shouting

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DIAGNOSISA detailed medical history should be obtained from birth onwards.
Additionally, standardized questionnaires may be used. The Child Behavior
Checklist (Achenbach, 1991) can be employed to obtain information concerning
possible comorbid disorders (see Chapter A.5). The Strengths and Difficulties
Questionnaire (Goodman, 1997) can also be recommended for this purpose (seeChapter A.5). Tic-specific or semi-structured interviews include the Yale Global Tic
Severity Scale (YGTSS) (Leckman et al, 1989) and the Tourette’s Syndrome Severity
Scale (TSSS) (Walkup et al, 1992). Parental or self-rating can be done using the
Yale Tourette Syndrome Symptom List-Revised (TSSL-R) (Leckman et al, 1989).
A thorough physical and neurological examination should be conducted,
including an EEG. The main purpose for this is to exclude other possible illnesses
that could cause the symptoms. Usually no further tests, such as an MRI, arenecessary unless there are pathological findings. ECG, thyroid function tests orother procedures (e.g., metabolic tests) are not necessary in the absence of abnormal
findings.
Tests of cognitive ability are not necessary either unless there is indicationof learning problems. Completing questionnaires provides a good opportunity toobserve the patient in a challenging situation, even though patients are often able
to suppress tics for a certain period so that the true extent of the symptoms may
not be observed.
Differential diagnosis and comorbidity
Specific circumstances may cause variation of tic symptoms. Emotional
states such as fear, joy or tension frequently lead to an increase. Distractions, anoccupation requiring high concentration and consumption of cannabis or alcohol
Table H.2.3 Differential diagnoses of motor tics (Roessner & Wanderer2010)
Aspect of tics

Disorder – differential diagnoses

Preoccupation with tic control

Attention problem

Tic repetition

Obsessive-compulsive phenomena“Exaggerated” tic1

Psychogenic origin

Monotonous tic

Stereotypy

Eye rolling

Absence

Rapid shuffling steps

Akathisia, juvenile Parkinson, compulsion

Distortions and similar2

Dystonia/ Dyskinesia

Convulsive grimacing

Blepharospasm“Jerky” tics

Chorea“Shuddering” tics

Myoclonus

Tics during sleep

Restless legs, epilepsy, parasomniasThis could be a movement or sound performed in an over-emphasized manner, therefore
lacking the suddenness or uncontrollability of a typical tic.
2
This would involve movements of a more coiling or writhing nature.
1

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Table H.2.4 Psychiatric disorders often associated with tic disorders
Comorbid disorder% of children with tic disorderaffected

Attention deficit hyperactivity disorder(ADHD)

40 – 60

Obsessive-compulsive symptoms

40 - 70

Anxiety disorders

25 – 40

Depressive symptoms

Around 50

Sleeping disorders

12 – 44

may lead to a decrease. Tics hardly ever interfere with intentional movements suchas cycling. It is possible for tics to appear during any of the sleep stages, albeit
with reduced frequency, intensity and complexity. Due to the aforementioned
characteristics, it is possible to differentiate tic symptoms from most othermovement disorders (see table H.2.3).
Approximately 65 % of children and adolescents with chronic motor or vocal
tic disorder have a comorbid condition (Conelea et al, in press). Around 90% of
those with TS develop one or more psychiatric disorders (Freeman, 2007). The
probability of having a comorbid disorder increases with the severity of tics, early
onset and familial loading.

TREATMENT
Psychoeducation
Psychoeducation, involving the patient as well as relevant caregivers, should
be provided at the beginning of treatment. Further, individual causal factors andoptions for treatment should be discussed. Referral to self-help groups is also
useful. Treatment is usually delivered as an out-patient; inpatient treatment canbe necessary in severe cases requiring more extensive investigations, when severecomorbid disorders are present or to monitor and achieve optimal drug treatment.
Figure H.2.2 shows a decision tree (Roessner et al, 2011).
Psychoeducation involves providing detailed information to the relevant
persons, in the case of young people this usually will involve parents and teachers.
Information should be provided regarding the disorder, its course, investigations
and options for treatment. Information which often is of use to teachers involves
recommending allowing the child to sit exams on their own or to be permitted toleave the classroom for short periods – to lessen the urge to release the tics.
In cases of mild severity – taking into account the high rate of spontaneous
remission – psychoeducation is all that is required. For this reason it makes sense to
adopt a “wait-and-see” approach, keeping a watchful eye on recurrences or possiblecomorbid disorders (Wanderer et al, 2012).
Psychotherapy
Cognitive behavioral methods are the most effective psychotherapeuticintervention. This treatment should be administered by trained professionals well

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Figure H.2.2 Decision tree for the treatment of tic disorders including Tourette syndrome(Roessner et al, 2011).

DBS: deep brain stimulation
THC: Tetrahydrocannabinol

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IACAPAP Textbook of Child and Adolescent Mental Healthversed in the complexities of the disorder. It may involve the following (Verdellen
et al, 2011):•

For well-motivated and insightful patients, habit reversal training has
been shown to be effective. Training comprises a set of techniques
intended to help patients become aware of impending tics andpracticing a competing response to inhibit or interrupt the tic. These
techniques include relaxation training, contingency management andgeneralization training. To heighten tic awareness, methods such as:−

Response description (patients learn to describe the topographyof their tics and develop a detailed, usually written, descriptionof each tic)−

Response detection (patients receive feedback concerning theoccurrence of a tic, until they can detect the target behavior
unassisted)−

Early warning procedures (patients practice identifying the earlysigns of a tic, such as specific urges, sensations or thoughts) and−

Situation awareness (patients describe people, places orsituations in which the tics occur most commonly) are includedin the training.

−

Competing response training involves the patient learning topurposefully initiate a tic for one to three minutes or until theurge to perform the tic has disappeared.

•

Exposure and response prevention is based on the association of apremonitory urge followed by the vocal or motor tic, which resultsin the relief of the urge sensation. The aim is to break the association
between the urge and the resultant tic, which – according to learningtheory – has been strengthened over time. By confronting the patientwith the premonitory urge over a longer period (exposure) and having
them resist giving in to it (response prevention), the patients would
learn to endure the urge without having to act out the tic (habituation).
Patients are also encouraged to self-monitor symptoms by recording
times and situations in which tics occur over certain periods to ascertain
when and where tics are most frequent.

•

Massed (negative) practice involves intentionally and repeatedly actingout the tic in an effortful and rapid way over a certain period with short
rests in between. The long-term effectiveness of this seems limited but
can help patients if they are about to enter situations which require ticfree appearance (i.e., going to the cinema).

•

Relaxation training is assumed to help reduce tics because tic intensity
often increases in times of stress and anxiety. Relaxation training
includes progressive muscle relaxation, imagery, autogenic training or
deep breathing and is mostly applied as one part of a multi-modal
treatment plan. In terms of effectiveness, Peterson and Azrin (1992)
found that tics were reduced by 32% with relaxation training, by
55% with habit reversal training and by 44% with self-monitoring
techniques.

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9IACAPAP Textbook of Child and Adolescent Mental Health•Contingency management, again as a part of a multi-modal program,seeks to positively reinforce tic-free intervals (e.g., through tokens,praise or demonstration of affection) and to ignore tics. According tolearning theory this should result in a lessening of the behavior (in thiscase, the occurrence of tics). Because this method is usually incorporated
in multi-component treatment packages, it has been difficult to assess
the value of this specific technique.

•

Sometimes the presence of a tic disorder in a child may result insignificant problems among family members. In such cases family
therapy should be recommended.

Medication
There is good empirical evidence supporting the use of a variety of
medications for Tourette syndrome (see below). However, medication for Tourette
syndrome is often prescribed “off-label”. For instance, the only drug approved
for tics in Germany is haloperidol, which on current evidence is considered only
a medication of third choice. Pharmacological treatment is recommended whentics result in significant subjective discomfort, such as muscular pain or physicalinjury, ongoing social problems (e.g., isolation or bullying), emotional problems,or significant functional impediment, typically in academic performance (Roessner
et al, 2011). The aim is to achieve the best balance between maximum benefit andminimum side effects. It is not to be expected that tics will disappear completely
with medication; at best, symptoms will be alleviated.
Before initiating pharmacological treatment, the following investigations
should be carried out: blood and liver function tests, prolactin levels, ECG,
EEG, as well as physical and neurological examinations (to establish a baseline,
exclude cardiac contraindications, including long QT syndromes, other physicalillnesses or potential contraindications for the use of medication ). Additionally,
it is important to assess whether the tic disorder or another comorbid disorderis causing the greatest impairment, in order to determine which of the disorders
should be primarily treated. For instance, treating comorbid ADHD can result in
improved ability to suppress the tics without having to specifically treat them –conversely, psychostimulant drugs may rarely worsen the tics.
Generally speaking, medication should start slowly, with effectiveness andtolerability being assessed at regular intervals. Once optimal dosage has been
ascertained, medication should be taken regularly for at least one year before
considering a discontinuation. At the very latest, medication should be reduced inlate adolescence to ascertain whether continuation is necessary, taking into accountthe high rates of spontaneous remission. Table H.2.5 summarizes the European
recommendations about medication for tic disorders.
•Haloperidol is the only medication officially approved for the treatmentof tic disorders in Europe (from the age of three years). Haloperidol
has strong antidopaminergic action and results in a reduction of tics
in approximately 80 % of cases. However, adverse reactions suchas extrapyramidal symptoms occur quite frequently, which makes
haloperidol not the treatment of first choice.

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Tic disorders

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A
B

Ziprasidone

Sulpiride

B

A

Risperidone

TiaprideC

C

Olanzapine

QuetapineC

Aripirazole

A

Haloperidol

AA

Guanfacine

PimozideA

Clonidine

Level ofevidence

2-10 mg/kg

2-10 mg/kg

50-100(2mg/kg)
50-100(2mg/kg)

5.0-10.0

0.25-6.0

100-600

2.5-102.5-300.25-15.0

0.25-15.0

1.0-4.0

0.1-0.3

Therapeutic
range (mg)5.0-10.0

0.25

100-150

2.5-102,50

0.25-0.5

0.25-0.5

0.5-1.0

0.05

Starting dosage(mg)

Problems with sleep
Agitation
Increased appetite
Sedation
Increased appetite

•
•
•
•
•

•

Sedation
Akathisia
EPS
HeadacheIncreased appetite,weightOrthostatic hypotension

EPS
Sedation
Increased appetite andweightOrthostatic hypotension
Sedation, sleepiness

•
•
•
•
•

•
•
•

•
•

Common adverse
effects•••••

Blood count
ECG
Weight, Transaminases
ProlactineElectrolytes

Blood countBlood pressure
WeightECG
Transaminases
Blood sugar and lipids

Blood count
ECG
WeightTransaminases
Neurologic status
Prolactine

•
•
•
•
•
•
•
•
•
•
•
•

Blood pressure
ECG

•
•

Investigations at start andduring follow up

EPS: extrapyramidal symptoms. Evidence level: A, >2 randomized controlled trials; B, 1 randomized controlled trial; C, anecdotal (case studies, open trials).

Benzamides

Second generation
antipsychotics

First generation
antipsychotics

Alpha-adrenergic
agonists

Medication

Table H.2.5 Medications with some evidence of effectiveness for the treatment of Tourette’s syndrome (Roessner et al, 2011)

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IACAPAP Textbook of Child and Adolescent Mental Health•

Tiapride is a selective D2 receptor antagonist that shows virtually no
antipsychotic action. It has a good side effect profile and is well tolerated
with few extrapyramidal symptoms. The most frequent adverse
reactions are drowsiness, moderate transient hyperprolactinemia andweight gain. There is no evidence of negative effects on children’s
cognitive performance. Tiapride is currently the first-choice medication
for treatment of Tourette syndrome in Germany.

•

Risperidone is a second generation antipsychotic agent with a highaffinity for D2 and 5-HT2 receptors. Efficacy is similar to that of
haloperidol but with a more favorable side effect profile (see Table
H.2.5).

•

Aripiprazole has shown promising effects specifically in patients who
had not responded to, or had not tolerated well other medications.
Aripiprazole has a high affinity for D2 receptors but, in contrast toother second generation antipsychotics, it is also a partial agonist of
5HT1A receptors and a potent antagonist at 5HT2A receptors. This
profile has raised hopes that it may be better than the other drugs(Roessner, 2011). It also has the advantage that weight gain is low.
Nausea and sedation are the most frequently reported adverse effects.

Although the best evidence from clinical trials is still that for the typicalantipsychotics haloperidol and pimozide, European clinical practice has gradually
substituted these substances with atypical antipsychotics, foremost risperidone.
Availability of and experience with specific medications, however, also plays a rolein the choice. In the German-speaking world, tiapride is regarded as the first choice
drug in the treatment of tic disorders in children and adolescents (Rothenberger
et al, 2007). Although evidence is comparatively limited, Roberston and Stern(2000) also recommend tiapride as well as sulpiride in their review of treatment
for tic disorders, due to their balance of efficacy and tolerability. Aripiprazole has
shown potential regarding efficacy in refractory cases. There is, however, a lack ofplacebo-controlled studies for this medication.
Treating Tourette syndrome comorbid with other disorders
When there are comorbid psychiatric disorders and Tourette syndrome, it
should always be ascertained which of the presenting conditions is causing thegreater impairment. Treating one disorder frequently has a positive effect on theother and may render further specific treatment unnecessary.
Attention deficit hyperactivity disorder (ADHD)
If ADHD is comorbid with a tic disorder, the former may be treatedwith psychostimulants, such as methylphenidate. There has been a longstandingargument about whether psychostimulants may cause, trigger or worsen tics
in these cases and, therefore, whether they should be contraindicated in thesecircumstances. Recent studies have shown that in most cases psychostimulants
do not lead to an exacerbation of tics (Pringsheim & Steeves, 2011). Treating
patients with atomoxetine or clonidine has proven effective as long as the Tourette
syndrome is only of mild to moderate severity (Roessner et al, 2011). These two
medications mainly reduce ADHD symptoms only having a marginal effect on

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IACAPAP Textbook of Child and Adolescent Mental Healthtics. Should the aforementioned medication have little effect on tics, the additionof risperidone can be considered. Alternatively, ADHD symptoms may be treatedwith methylphenidate, which can be combined with risperidone if necessary.
Emotional disorders
In cases presenting with mild to moderate depressive or anxious symptoms
comorbid with Tourette syndrome, pharmacological treatment solely with sulpiride
can be considered. Sulpiride has positive effects on tics as well as the comorbid
emotional problems with few extrapyramidal symptoms and vegetative adverse
reactions (Roessner et al, 2011), with the exception of galactorrhea.
Another option for treating Tourette syndrome with comorbid depression
or obsessive-compulsive disorder is using a selective serotonin reuptake-inhibitor(SSRI). Antipsychotic drugs can be prescribed in combination with SSRIs in casesof moderate to severe tic symptoms.
Alternative medicine treatments
Substantial anecdotal evidence exists concerning the benefits of physicalactivity (rhythmic sports, such as swimming) and recreational activities in general.
Patients should be informed and encouraged accordingly. There is no evidence that
diet, vitamins or mineral supplements as well as hypnosis are of benefit and should
not be recommended.

REFERENCES
Achenbach T (1991). Manual for the Child Behavior
Checklist/4-18 and 1991 Profile. Burlington: Universityof Vermont, Department of Psychiatry.

Goodman R (1997). The Strengths and Difficulties
Questionnaire: a research note. Journal of Child
Psychology and Psychiatry, 38:581-586.

American Psychiatric Association (1994). Diagnostic andStatistical Manual of Mental Disorders, 4th ed.
Washington: American Psychiatric Association.

Kerbeshian J, Burd L (1992). Epidemiology and comorbidity.
The North Dakota prevalence studies of Tourette
syndrome and other developmental disorders.
Advances in Neurology, 58:67-74.

Banaschewski T, Woerner W, Rothenberger A (2003).
Premonitory sensory phenomena and suppressibilityof tics in Tourette syndrome: developmental aspects inchildren and adolescents. Developmental Medicine andChild Neurology, 45:700-703.
Burd L, Severud R, Klug MG et al (1999). Prenatal and perinatal
risk factors for Tourette disorder, Journal of Perinatal
Medicine, 27:295-302.
Conelea CA, Woods DW, Zinner SH et al (in press). The
Impact of Tourette syndrome in adults: Results fromthe Tourette syndrome impact survey. Community
Mental Health Journal.
Erenberg G, Cruse RP, Rothner AD (1987). The natural historyof Tourette syndrome: a follow-up study’, Annals of
Neurology, 22:383-385.
Freeman RD (2007). Tic disorders and ADHD: answers froma world-wide clinical dataset on Tourette syndrome.
European Child & Adolescent Psychiatry, 16(supp1):1523.

Tic disorders

H.2

Leckman JF, Peterson BS, Anderson GM et al (1997).
Pathogenesis of Tourette’s syndrome. Journal of Child
Psychology and Psychiatry, 38:119-142.
Leckman JF, Riddle MA, Hardin MT et al (1989). The Yale
Global Tic Severity Scale: initial testing of a clinicianrated scale of tic severity. Journal of the American
Academy of Child & Adolescent Psychiatry, 28:566-573.
Leckman JF, Zhang H, Vitale A et al (1998). Course of tic
severity in Tourette syndrome: the first two decades.
Pediatrics, 102:14-19.
Mathews CA, Bimson B, Lowe TL et al (2006). Association
between maternal smoking and increased symptom
severity in Tourette’s syndrome. The American Journalof Psychiatry, 163:1066-1073.
O’Rourke JA, Scharf JM, Platko J et al (2011). The familial
association of Tourette’s disorder and ADHD: theimpact of OCD symptoms. American Journal of
Medical Genetics. Part B, Neuropsychiatric Genetics,
156B:553-560.

13

IACAPAP Textbook of Child and Adolescent Mental HealthPeterson AL, Azrin NH (1992). An evaluation of behavioral
treatments for Tourette syndrome. Behaviour Research
and Therapy, 30:167-174.
Pringsheim T, Steeves T (2011). Pharmacological treatment for
Attention Deficit Hyperactivity Disorder (ADHD)in children with comorbid tic disorders. Cochrane
Database of Systematic Reviews, no 4:CD007990.
Robertson MM (2008). The prevalence and epidemiology ofGilles de la Tourette syndrome. Part 2: tentative
explanations for differing prevalence figures in GTS,
including the possible effects of psychopathology,
aetiology, cultural differences, and differing
phenotypes. Journal of Psychosomatic Research, 65:473486.
Robertson MM, Eapen V, Cavanna AE (2009). The international
prevalence, epidemiology, and clinical phenomenology
of Tourette syndrome: a cross-cultural perspective.
Journal of Psychosomatic Research, 67:475-483.
Robertson MM, Stern JS (2000). Gilles de la Tourette syndrome:
symptomatic treatment based on evidence. European
Child & Adolescent Psychiatry, 9 (supp 1):I60-175.
Roessner V, Banaschewski T, Rothenberger A (2004). [Therapyof tic-disorders]. Zeitschrift Für Kinder- Und
Jugendpsychiatrie Und Psychotherapie, 32:245-263.
Roessner V, Plessen KJ, Rothenberger A et al (2011). European
clinical guidelines for Tourette syndrome and othertic disorders. Part II: pharmacological treatment.
European Child & Adolescent Psychiatry, 20:173-196.
Roessner V, Wanderer S (2010). [Tic- Störungen in derKinderarztpraxis]. PÄD Prak­ti­sche Päd­ia­trie, 16:179183
Rothenberger A, Banaschewski T, Roessner V (2007). [TicStörungen. In: Deutsche Gesellschaft für Kinder- undJugendpsychiatrie PuP (ed) Leitlinien zur Diagnostik
und Therapie von psychischen Störungen im Säuglings-,
Kindes- und Jugendalter.] Köln: Deutscher Ärzteverlag.

Tic disorders

H.2

Rothenberger A, Roessner V, Banaschewski et al (2007).
Co-existence of tic disorders and attentiondeficit/hyperactivity disorder-recent advances inunderstanding and treatment’, European Child &Adolescent Psychiatry, 16 (supp 1):1-4.
Sandor P, Musisi S, Moldofsky H et al (1990). Tourette
syndrome: a follow-up study. Journal of ClinicalPsychopharmacology, 10:197-199.
Singer HS (2011). Tourette syndrome and other tic disorders.
In PJ Vinken, GW Bruyn (eds) Handbook of Clinical
Neurology, 100:641-657.
Singer HS, Walkup JT (1991). Tourette syndrome and other tic
disorders. Diagnosis, pathophysiology, and treatment.
Medicine, 70:15-32.
Staley D, Wand R, Shady G (1997). Tourette disorder: a crosscultural review’, Comprehensive Psychiatry, 38:6-16.
Steinberg T, Shmuel Baruch S, Harush A et al (2010). Tic
disorders and the premonitory urge. Journal of Neural
Transmission, 117:277-284.
Verdellen C, van de Griendt J, Hartmann A (2011). European
clinical guidelines for Tourette syndrome and othertic disorders. Part III: behavioural and psychosocial
interventions, European Child & Adolescent Psychiatry,
20:197-207.
Walkup JT, Rosenberg LA, Brown J et al (1992). The validityof instruments measuring tic severity in Tourette’s
syndrome. Journal of the American Academy of Childand Adolescent Psychiatry, 31:472-477.
Wanderer S, Roessner V, Freeman R et al (2012). Relationshipof obsessive-compulsive disorder to age-relatedcomorbidity in children and adolescents with Tourette
syndrome. Journal of Developmental and Behavioral
Pediatrics, 33:124-133.
World Health Organisation (1996). Multiaxial Classification ofChild and Adolescent Psychiatric Disorders: The ICD10 Classification of Mental and Behavioural Disorders
in Children and Adolescents. Cambridge: Cambridge
University Press.

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