A comparison of pimozide and haloperidol in the treatment of Gilles de la Tourette's syndrome

Pharmacological treatment of Tourette's syndrome: from the past to the future

Tourette's syndrome (TS) is a neuropsychiatric disease featuring tics and vocal tics, with a prevalence of approximately 1%, including 75% of the total number of male patients. TS seriously disturbs the patients' career, education, and life and brings a serious and unbearable psychological burden to the patients themselves and their families. At present, there are no specific clinical medications recommended for treating TS. Therefore, it is necessary to select the appropriate medication for symptomatic treatment based on the doctor's personal experience and the patient's symptoms, with the main goal of relieving symptoms, thus improving the patient's social skills and psychological problems. Here we conducted a comprehensive search on PubMed to review and organize the history and current status of the development of drug therapy for TS through a timeline format. We also systematically evaluated the effects of each drug for TS treatment to summarize the current problems and new research directions and to provide some ideas for clinical treatment.

Pharmacological treatment for Tourette syndrome in children and adults: What is the quality of the evidence? A systematic review

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental disorder characterised by involuntary muscle movements manifesting as motor and vocal tics. In the majority, tics are manageable without medication. Where tics cause discomfort or impair function, behavioural or pharmaceutical treatments may be considered.

AIMS

To provide a meticulous examination of the quality of evidence for the current pharmacological treatments for TS.

METHODS

PubMed and Google Scholar were searched to identify randomised, placebo-controlled trials (RCTs) of aripiprazole, risperidone, clonidine, guanfacine, haloperidol, pimozide, tiapride and sulpiride for the treatment of tics in children and adults with TS. Quality of reporting and risk of bias were assessed against the CONSORT checklist and Cochrane risk of bias criteria, respectively.

RESULTS

Seventeen RCTs were identified. Response rates reached 88.6% for aripiprazole, 68.9% for clonidine, 62.5% for risperidone and 19% for guanfacine. Statistically significant improvements were reported for all medications compared to placebo in at least one study and for at least one measure of tic severity. Most studies predated the CONSORT and Cochrane criteria and did not score highly when assessed on these measures.

CONCLUSIONS

There are relatively few placebo-controlled trials of commonly prescribed medications. Studies are often of poor quality and short duration. There is evidence for the efficacy of each medication, but no drug is clearly superior. Clonidine and guanfacine are better tolerated than antipsychotics, but less effective. There is too little evidence to determine whether adults respond differently from children.

A Comprehensive Review of Tic Disorders in Children

Tics are characterized by sudden, rapid, recurrent, nonrhythmic movement or vocalization, and are the most common movement disorders in children. Their onset is usually in childhood and tics often will diminish within one year. However, some of the tics can persist and cause various problems such as social embarrassment, physical discomfort, or emotional impairments, which could interfere with daily activities and school performance. Furthermore, tic disorders are frequently associated with comorbid neuropsychiatric symptoms, which can become more problematic than tic symptoms. Unfortunately, misunderstanding and misconceptions of tic disorders still exist among the general population. Understanding tic disorders and their comorbidities is important to deliver appropriate care to patients with tics. Several studies have been conducted to elucidate the clinical course, epidemiology, and pathophysiology of tics, but they are still not well understood. This article aims to provide an overview about tics and tic disorders, and recent findings on tic disorders including history, definition, diagnosis, epidemiology, etiology, diagnostic approach, comorbidities, treatment and management, and differential diagnosis.

Pediatric Prevention: Tic Disorders

It is not clear whether the development of tics can be prevented. Contextual variables can impact tic expression; therefore, shifting attention to behaviors that reduce tics is an important part of decreasing tic severity. Several medications are effective in reducing tic severity, but side effects restrict their use. Behavioral treatment is the gold standard psychotherapy intervention for tic disorders, with Comprehensive Behavioral Intervention for Tics being the most well-supported nonpharmacological treatment. Although children may be unable to prevent the development of tics, they can still use several strategies to reduce tic severity and impairment.

Current pharmacotherapy for tic disorders

Introduction: Though many unanswered questions about the pathophysiology of Tourette Syndrome remain, several pharmacotherapies for tics have been studied, with varying results in terms of efficacy and the strength of evidence.Areas covered: This literature review encompasses pharmacotherapies for tics. The pharmacotherapies discussed in this review include: alpha agonists, antipsychotics, topiramate, botulinum toxin, and dopamine depleters.Expert opinion: Once the presence of tics is confirmed and psychoeducation and support are provided to patients and caregivers, one must examine the degree of tic-related impairment and the presence of psychiatric comorbidities. These factors influence treatment decisions as the presence of comorbidity and related impairment may shift the treatment target. When selecting a medication for tics, the presence of ADHD (the most frequent comorbidity) strengthens the case for choosing an alpha agonist. The case for antipsychotic medications is strongest when tic-related impairment is severe and/or the tics are refractory to more conservative measures. All medications require drug safety monitoring procedures and reevaluation over time.

Drug and Non-drug Treatment of Tourette Syndrome

Background:

Tourette Syndrome (TS) is a neurodevelopmental disorder characterized by multiple repetitive motor and vocal tics. In most patients, its clinical course has a waxing and waning nature and most patients, usually children, will benefit from tolerant environmental and psychoeducation. Patients with more complicated tics, in particular, those with significant comorbidities will require drug therapy.

Objective:

The present paper is a mini-review of the current therapeutic arsenal for TS with reference to drug and non-drug management approach.

Methods:

A systematic survey of medical literature regarding the treatment decision making and the reported clinical trials or accumulating experience with different medications or other therapeutic modalities which were proven beneficial over the years.

Results:

Reviewing the literature indicates that dopamine antagonists, such as haloperidol and pimozoide, are the most reliable agents in terms of treatment response. Due to numerous adverse effects, newer atypical anti-psychotic drugs have been shown effective. Other widely accepted medications include alpha-2 adrenergic agonists, benzamides, dopamine depleting agents, benzodiazepines and dopamine depleting agents. In more selective and intractable cases botulinum toxin, dopamine agonists and cannabinoids should be also considered. Non-pharmacologic therapies reported beneficial effects, which include on the one hand, non-invasive behavioral techniques, such as comprehensive behavior therapy for tics. While on the other hand, in cases with particular protracted pharmaco-resistant tics electric stimulation techniques, such as deep brain stimulation, have been shown to be successful.

Conclusion:

Currently, there are numerous multifarious options for treatment of tics and other comorbid symptoms of TS. Nevertheless, treatment options and decision-making algorithms are still a clinical challenge.

Area Covered:

A step by step decision-making and various drugs and non-pharmacologic modalities appropriate for the management of TS.

Update on the Pharmacological Treatment of Tics with Dopamine-Modulating Agents

More than 40 years of research and clinical practice have proven the effectiveness of dopamine receptor antagonists in the pharmacological treatment of tics. A blockade of the striatal dopamine-D2 receptors is mainly responsible for their tic-reducing effect. A broad spectrum of dopamine-modulating agents, such as typical and atypical antipsychotics, but also dopamine receptor agonists are used with an immanent discord between experts about which of them should be considered as first choice. The present Review outlines the state of the art on pharmacological treatment of tics with dopamine-modulating agents by giving an systematic overview of studies on their effectiveness and a critical discussion of their specific adverse effects. It is considered as an update of a previous review of our research group published in 2013. The Review closes with a description of the current resulting treatment recommendations including the results of a first published revised survey on European expert's prescription preferences. Based on the enormously growing evidence on its effectiveness and safety, aripiprazole currently seems to be the most promising agent in the pharmacological treatment of tics. Furthermore, benzamides (especially tiapride), which are commonly used in Europe, have proven their excellent effectiveness-tolerability profile over decades in clinical practice and are therefore also highly recommended for the treatment of tics. Nevertheless, pharmacological treatment of tics remains an indiviual choice depending on each patient's own specific needs.

Tic Disorders and PANDAS

Tics are the most common movement disorder in childhood and are a frequent reason for referral to child neurology clinics. The purpose of this review is to examine the phenomenology of tics, discuss what is known regarding their genetic and pathophysiological causes and to evaluate current treatment options. The evidence for the evaluation and treatment of the controversial diagnosis of pediatric autoimmune neuropsychiatric disorders associated with group A streptococci (PANDAS) will also be reviewed. With improved understanding of tic disorders, their etiology and response to current treatment options, we may be able to more effectively diagnose them and identify novel treatment strategies.

Current Approaches and New Developments in the Pharmacological Management of Tourette Syndrome

Tourette syndrome (TS) is a neurodevelopmental disorder of unknown etiology characterized by spontaneous, involuntary movements and vocalizations called tics. Once thought to be rare, TS affects 0.3-1% of the population. Tics can cause physical discomfort, emotional distress, social difficulties, and can interfere with education and desired activities. The pharmacologic treatment of TS is particularly challenging, as currently the genetics, neurophysiology, and neuropathology of this disorder are still largely unknown. However, clinical experience gained from treating TS has helped us better understand its pathogenesis and, as a result, derive treatment options. The strongest data exist for the antipsychotic agents, both typical and atypical, although their use is often limited in children and adolescents due to their side-effect profiles. There are agents in a variety of other pharmacologic categories that have evidence for the treatment of TS and whose side-effect profiles are more tolerable than the antipsychotics; these include clonidine, guanfacine, baclofen, topiramate, botulinum toxin A, tetrabenazine, and deutetrabenazine. A number of new agents are being developed and tested as potential treatments for TS. These include valbenazine, delta-9-tetrahydrocannabidiol, and ecopipam. Additionally, there are agents with insufficient data for efficacy, as well as agents that have been shown to be ineffective. Those without sufficient data for efficacy include clonazepam, ningdong granule, 5-ling granule, omega-3 fatty acids, and n-acetylcysteine. The agents that have been shown to be ineffective include pramipexole and metoclopramide. We will review all of the established pharmacologic treatments, and discuss those presently in development.

Tourette syndrome and other chronic tic disorders: an update on clinical management

INTRODUCTION

The management of Tourette syndrome (TS) and other chronic tic disorders occurs in multiple stages and begins with comprehensive assessment and complex psychoeducation. Behavioral and pharmacological interventions (second stage) are needed when tics cause physical or psychosocial impairment. Deep brain stimulation surgery or experimental therapies represent the third stage. Areas covered: Discussed are recent advances in assessment and therapy of chronic tic disorders, encompassing the three stages of intervention, with the addition of experimental, non-invasive brain stimulation strategies. A PubMed search was performed using as keywords: 'tic disorders', 'Tourette syndrome', 'assessment', 'rating scales', 'behavioral treatment', 'pharmacological treatment', 'deep brain stimulation', 'transcranial magnetic (or current) stimulation', and 'transcranial current stimulation'. More than 300 peer-reviewed articles were evaluated. The studies discussed have been selected on the basis of novelty and impact. Expert commentary: Comprehensive assessment of tic disorders and psychoeducation are crucial to a correct active management approach. Behavioral treatments represent first line of active interventions, with increasing potential offered by telehealth. Antipsychotics and alpha agonists remain first line pharmacological interventions for tics, although VMAT-2 inhibitors appear promising. Deep brain stimulation is a potential option for medically refractory, severely disabled patients with tics, but age and target selection require further investigation.

Tics in the Pediatric Population: Pragmatic Management

BACKGROUND

Primary tic disorders, notably Tourette syndrome, are very common movement disorders in childhood. However, the management of such patients still poses great therapeutic challenges to medical professionals.

METHODS

Based on a synthesis of the available guidelines published in Europe, Canada, and the United States, coupled with more recent therapeutic developments, the authors provide a pragmatic guide to aid clinicians in deciding when and how to treat patients who have primary tic disorders.

RESULTS

After a systematic assessment of tics and common neuropsychiatric comorbidities (primarily attention-deficit hyperactivity disorder [ADHD] and obsessive-compulsive disorder [OCD]), the first step in treatment is a comprehensive psychoeducation of patients and families that addresses the protean phenomenology of tics and associated behaviors, coping mechanisms, prognosis, and treatment options. When more active intervention beyond watchful monitoring is indicated, hierarchical evaluation of treatment targets (i.e., tics vs. comorbid behavioral symptoms) is crucial. Behavioral treatments for tics are restricted to older children and are not readily available to all centers, mainly due to the paucity of well-trained therapists. Pharmacological treatments, such as antipsychotics for tics, stimulants and atomoxetine for ADHD, and α2A-agonists for children with tics plus ADHD, represent widely available and effective treatment options, but safety monitoring must be provided. Combined polypharmacological and behavioral/pharmacological approaches, as well as neuromodulation strategies, remain under-investigated in this population of patients.

CONCLUSIONS

The treatment of children with tics and Tourette syndrome is multifaceted. Multidisciplinary teams with expertise in neurology, psychiatry, psychology, and pediatrics may be helpful to address the complex needs of these children.

Case of Secondary Tics Associated With Olanzapine in an Adult

Atypical antipsychotic medications, such as risperidone, aripiprazole, and olanzapine, have utility in treating motor tics, particularly in Tourette syndrome. In rare cases, atypical antipsychotic medications have been associated with adult-onset motor tics. Such adverse drug reactions have been documented in response to quetiapine, aripiprazole, and amisulpride. Here, we report, to our knowledge, the first case of adult-onset motor tics related to olanzapine administration.

Clinical effectiveness and patient perspectives of different treatment strategies for tics in children and adolescents with Tourette syndrome: a systematic review and qualitative analysis

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental condition characterised by chronic motor and vocal tics affecting up to 1% of school-age children and young people and is associated with significant distress and psychosocial impairment.

OBJECTIVE

To conduct a systematic review of the benefits and risks of pharmacological, behavioural and physical interventions for tics in children and young people with TS (part 1) and to explore the experience of treatment and services from the perspective of young people with TS and their parents (part 2).

DATA SOURCES

For the systematic reviews (parts 1 and 2), mainstream bibliographic databases, The Cochrane Library, education, social care and grey literature databases were searched using subject headings and text words for tic* and Tourette* from database inception to January 2013.

REVIEW/RESEARCH METHODS

For part 1, randomised controlled trials and controlled before-and-after studies of pharmacological, behavioural or physical interventions in children or young people (aged < 18 years) with TS or chronic tic disorder were included. Mixed studies and studies in adults were considered as supporting evidence. Risk of bias associated with each study was evaluated using the Cochrane tool. When there was sufficient data, random-effects meta-analysis was used to synthesize the evidence and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. For part 2, qualitative studies and survey literature conducted in populations of children/young people with TS or their carers or in health professionals with experience of treating TS were included in the qualitative review. Results were synthesized narratively. In addition, a national parent/carer survey was conducted via the Tourettes Action website. Participants included parents of children and young people with TS aged under 18 years. Participants (young people with TS aged 10-17 years) for the in-depth interviews were recruited via a national survey and specialist Tourettes clinics in the UK.

RESULTS

For part 1, 70 studies were included in the quantitative systematic review. The evidence suggested that for treating tics in children and young people with TS, antipsychotic drugs [standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -1.08 to -0.41; n = 75] and noradrenergic agents [clonidine (Dixarit(®), Boehringer Ingelheim) and guanfacine: SMD -0.72, 95% CI -1.03 to -0.40; n = 164] are effective in the short term. There was little difference among antipsychotics in terms of benefits, but adverse effect profiles do differ. Habit reversal training (HRT)/comprehensive behavioural intervention for tics (CBIT) was also shown to be effective (SMD -0.64, 95% CI -0.99 to -0.29; n = 133). For part 2, 295 parents/carers of children and young people with TS contributed useable survey data. Forty young people with TS participated in in-depth interviews. Four studies were in the qualitative review. Key themes were difficulties in accessing specialist care and behavioural interventions, delay in diagnosis, importance of anxiety and emotional symptoms, lack of provision of information to schools and inadequate information regarding medication and adverse effects.

LIMITATIONS

The number and quality of clinical trials is low and this downgrades the strength of the evidence and conclusions.

CONCLUSIONS

Antipsychotics, noradrenergic agents and HRT/CBIT are effective in reducing tics in children and young people with TS. The balance of benefits and harms favours the most commonly used medications: risperidone (Risperdal(®), Janssen), clonidine and aripiprazole (Abilify(®), Otsuka). Larger and better-conducted trials addressing important clinical uncertainties are required. Further research is needed into widening access to behavioural interventions through use of technology including mobile applications ('apps') and video consultation.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002059.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Treatment-refractory Tourette Syndrome

Tourette Syndrome (TS) is a complex neurodevelopmental condition marked by tics and frequently associated with psychiatric comorbidities. While most cases are mild and improve with age, some are treatment-refractory. Here, we review strategies for the management of this population. We begin by examining the diagnosis of TS and routine management strategies. We then consider emerging treatments for refractory cases, including deep brain stimulation (DBS), electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and novel pharmacological approaches such as new vesicular monoamine transporter type 2 inhibitors, cannabinoids, and anti-glutamatergic drugs.

Tourette Syndrome: Bridging the Gap between Genetics and Biology

Tourette syndrome is a childhood neuropsychiatric disorder, which presents with disruptive motor and vocal tics. The disease also has a high comorbidity with obsessive-compulsive disorder and attention deficit hyperactivity disorder, which may further increase the distress experienced by patients. Current treatments act with varying efficacies in alleviating symptoms, as the underlying biology of the disease is not fully understood to provide precise therapeutic targets. Moreover, the genetic complexity of the disorder presents a substantial challenge to the identification of genetic alterations that contribute to the Tourette's phenotype. Nevertheless, genetic studies have suggested involvement of dopaminergic, serotonergic, glutamatergic, and histaminergic pathways in the pathophysiology of at least some cases. In addition, genetic overlaps with other neuropsychiatric disorders may point toward a shared biology. The findings that are emerging from genetic studies will allow researchers to piece together the underlying components of the disease, in the hopes that a deeper understanding of Tourette's can lead to improved treatments for those affected by it.

The role of atypical antipsychotics for treatment of Tourette's syndrome: an overview

Tourette's syndrome (TS) is a neuropsychiatric disorder of childhood onset characterized by multiple motor and phonic tics that fluctuate over time. Tic symptoms often improve by late adolescence, but some children and adults with TS may experience significant tic-related morbidity, including social and family problems, academic difficulties, and pain. When more conservative interventions are not successful, and when certain psychiatric co-morbidities further complicate the clinical profile, treating TS with an atypical antipsychotic medication may be a reasonable second-tier approach. However, the evidence supporting efficacy and safety of the atypical antipsychotics for treatment of tics is still very limited. The objective of this paper is to provide an updated overview of the role of atypical antipsychotics for treatment of TS, with evidence-based guidance on their use. Evidence for efficacy of different typical and atypical antipsychotics for treatment of tics was examined by conducting a systematic, keyword-related search of 'atypical antipsychotics' and 'Tourette's syndrome' in PubMed (National Library of Medicine, Washington, DC, USA). Four recent treatment consensus publications were also reviewed. This review focused on literature published from 2000 to 2013 and on available randomized controlled trials in TS. Evidence supporting the use of atypical antipsychotics for treatment of TS is limited. There are few randomized medication treatment trials in TS (i.e. risperidone, aripiprazole, ziprasidone), which employed varying methodologies, thereby restricting meaningful comparisons among studies. Future collaborations among clinical sites with TS expertise employing high-quality study design may better elucidate the role of atypical antipsychotics for treatment of TS.

Advances in Tourette syndrome: diagnoses and treatment

Tourette syndrome (TS) is a childhood-onset neurodevelopmental disorder characterized by multiple motor tics and at least one vocal or phonic tic, and often one or more comorbid psychiatric disorders. Premonitory sensory urges before tic execution and desire for "just-right" perception are central features. The pathophysiology involves cortico-striato-thalamo-cortical circuits and possibly dopaminergic system. TS is considered a genetic disorder but the genetics is complex and likely involves rare mutations, common variants, and environmental and epigenetic factors. Treatment is multimodal and includes education and reassurance, behavioral interventions, pharmacologic, and rarely, surgical interventions.

A case of sudden death after Japanese encephalitis vaccination

Japanese encephalitis (JE) virus is estimated to result in 3500-50,000 clinical cases every year, with mortality rates of up to 20-50% and a high percentage of neurological sequelae in survivors. Vaccination is the single most important measure in preventing this disease. Inactivated Vero cell culture-derived JE vaccines have not been linked to any fatalities, and few serious adverse events after vaccination have been reported. Here, we report a case of sudden death in which a 10-year-old boy experienced cardiopulmonary arrest 5 min after receiving a Japanese encephalitis vaccination. He had been receiving psychotropic drugs for the treatment of pervasive developmental disorders. Postmortem examinations were nonspecific, and no signs of dermatologic or mucosal lesions or an elevation of the serum tryptase level, which are characteristic of anaphylaxis, were observed. A toxicological examination revealed that the blood concentrations of the orally administered psychotropic drugs were within the therapeutic ranges. The patient was considered to have died of an arrhythmia that was not directly associated with the vaccination.

Clinical pharmacology of dopamine-modulating agents in Tourette's syndrome

Forty years of research and clinical practice have proved dopamine (DA) receptor antagonists to be effective agents in the treatment of Tourette's syndrome (TS), allowing a significant tic reduction of about 70%. Their main effect seems to be mediated by the blockade of the striatal DA-D2 receptors. Various typical and atypical agents are available and there is still discord between experts about which of them should be considered as first choice. In addition, there are suggestions to use DA receptor agonists such as pergolide or non-DA-modulating agents. The present chapter is focusing on the clinical pharmacology of DA-modulating agents in the treatment of TS. The introduction outlines their clinical relevance and touches on the hypotheses of the role of DA in the pathophysiology of TS. Subsequently, general information about the mechanisms of action and adverse effects are provided. The central part of the chapter forms a systematic review of all DA-modulating agents used in the treatment of TS, including an overview of studies on their effectiveness, and a critical discussion of their specific adverse effects. The present chapter closes with a summary of the body of evidence and a description of the resulting recommendations for the pharmacological treatment of TS.

Systematic review: pharmacological treatment of tic disorders--efficacy of antipsychotic and alpha-2 adrenergic agonist agents

We conducted a meta-analysis of randomized, placebo-controlled trials to determine the efficacy of antipsychotic and alpha-2 agonists in the treatment of chronic tic disorders and examine moderators of treatment effect. Meta-analysis demonstrated a significant benefit of antipsychotics compared to placebo (standardized mean difference (SMD)=0.58 (95% confidence interval (CI): 0.36-0.80). Stratified subgroup analysis found no significant difference in the efficacy of the 4 antipsychotic agents tested (risperidone, pimozide, haloperidol and ziprasidone). Meta-analysis also demonstrated a benefit of alpha-2 agonists compared to placebo (SMD=0.31 (95% confidence interval CI: 0.15-0.48). Stratified subgroup analysis and meta-regression demonstrated a significant moderating effect of co-occurring ADHD. Trials which enrolled subjects with tics and ADHD demonstrated a medium-to-large effect (SMD=0.68 (95%CI: 0.36-1.01) whereas trials that excluded subjects with ADHD demonstrated a small, non-significant benefit (SMD=0.15 (95%CI: -0.06 to 0.36). Our findings demonstrated significant benefit of both antipsychotics and alpha-2 agonists in treating tics but suggest alpha-2 agonists may have minimal benefit in tic patients without ADHD.

Pediatric indications for deep brain stimulation

PURPOSE

Based on the success of deep brain stimulation (DBS) in the treatment of adult disorders, it is reasonable to assume that the application of DBS in the pediatric population is an emerging area worthy of study. The purpose of this paper is to outline the current movement disorder indications for DBS in the pediatric population, and to describe areas of investigation, including possible medically refractory psychiatric indications.

METHODS

We performed a structured review of the English language literature from 1990 to 2011 related to studies of DBS in pediatrics using Medline and PubMed search results.

RESULTS

Twenty-four reports of DBS in the pediatric population were found. Based on published data on the use of DBS for pediatric indications, there is a spectrum of clinical evidence for the use of DBS to treat different disorders. Dystonia, a disease associated with a low rate of remission and significant disability, is routinely treated with DBS and is currently the most promising pediatric application of DBS. We caution the application of DBS to conditions associated with a high remission rate later in adulthood, like obsessive-compulsive disorder and Tourette's syndrome. Moreover, epilepsy and obesity are currently being investigated as indications for DBS in the adult population; however, both are associated with significant morbidity in pediatrics.

CONCLUSION

While currently dystonia is the most promising application of DBS in the pediatric population, multiple conditions currently being investigated in adults also afflict children and adolescents, and thus warrant further research.

Canadian guidelines for the evidence-based treatment of tic disorders: pharmacotherapy

This article seeks to provide the practising clinician with guidance on the pharmacological management of tic disorders in children and adults. We performed a systematic review of the literature on the treatment of tic disorders. A multi-institutional group of 14 experts in psychiatry, child psychiatry, neurology, pediatrics, and psychology engaged in a consensus meeting. The evidence was presented and discussed, and nominal group techniques were employed to arrive at consensus on recommendations. A strong recommendation is made when the benefits of treatment clearly outweigh the risks and burdens, and can apply to most patients in most circumstances without reservation. With a weak recommendation, the benefits, risks, and burdens are more closely balanced, and the best action may differ depending on the circumstances. Based on these principles, weak recommendations were made for the use of pimozide, haloperidol, fluphenazine, metoclopramide (children only), risperidone, aripiprazole, olanzapine, quetiapine, ziprasidone, topiramate, baclofen (children only), botulinum toxin injections, tetrabenazine, and cannabinoids (adults only). Strong recommendations were made for the use of clonidine and guanfacine (children only). While the evidence supports the efficacy of many of the antipsychotics for the treatment of tics, the high rates of side effects associated with these medications resulted in only weak recommendations for these drugs. In situations where tics are not severe or disabling, the use of a medication with only a weak recommendation is not warranted. However, when tics are more distressing and interfering, the need for tic suppression to improve quality of life is stronger, and patients and clinicians may be more willing to accept the risks of pharmacotherapy.

Update on the role of antipsychotics in the treatment of Tourette syndrome

Tourette syndrome (TS) is a neuropsychiatric disorder with typical onset in childhood and characterized by chronic occurrence of motor and vocal tics. The disorder can lead to serious impairments of both quality of life and psychosocial functioning, particularly for those individuals displaying complex tics. In such patients, drug treatment is recommended. The pathophysiology of TS is thought to involve a dysfunction of basal ganglia-related circuits and hyperactive dopaminergic innervations. Congruently, dopamine receptor antagonism of neuroleptics appears to be the most efficacious approach for pharmacological intervention. To assess the efficacy of the different neuroleptics available, a systematic, keyword-related search in PubMed (National Library of Medicine, Washington, DC) was undertaken. Much information on the use of antipsychotics in the treatment of TS is based on older data. Our objective was to give an update and therefore we focused on papers published in the last decade (between 2001 and 2011). Accordingly, the present review aims to summarize the current and evidence-based knowledge on the risk-benefit ratio of both first and second generation neuroleptics in TS.

New treatments for tic disorders

Tics vary in severity from infrequent and barely noticeable to nearly continuous and highly disruptive. Treatment of tic disorders depends on the severity of the tics, the distress they cause, and the effects they have on school, work, or daily activities. Many tics do not interfere with school or everyday life and do not require specific treatment. Comorbid disorders such as attention deficit hyperactivity disorder, anxiety, and obsessive-compulsive disorder occur in more than 50% of patients. The associated comorbidity can be more bothersome than the tics themselves. Treatment should be aimed at the most troubling symptom. Education and reassurance are often sufficient for mild and occasional tics. For tics of moderate severity, clonidine and guanfacine have a reasonable safety profile. They are considered as first-line medications. With clonidine, start with 0.05 mg at bedtime. Increase as needed and as tolerated by 0.05 mg every 4 to 7 days to a maximum dosage of 0.3 to 0.4 mg/day divided three or four times a day. With guanfacine, start with 0.5 mg at bedtime. The dosage may be increased as needed and as tolerated by 0.5 mg every week to a maximum dosage of 3 to 4 mg/day, divided twice a day. There are emerging data that behavioral therapy is effective for treatment of tics in some individuals. Dopamine receptor blockers are the most potent medications for treating severe tics. The efficacy appears to be proportionate to the affinity for dopamine D2 receptors. Thus, standard antipsychotic medications such as haloperidol, pimozide, or fluphenazine are the most potent. However, these medications commonly cause bothersome side effects. Therefore, we recommend use of atypical neuroleptics before standard neuroleptics in most patients. Risperidone is usually the first choice and may have efficacy for behavior problems that often accompany tics. Start with 0.01 mg/kg/dose once a day; dosage may be increased by 0.02 mg/kg/day at weekly intervals, up to 0.06 mg/kg/dose once a day. Ziprasidone and olanzapine are reasonable alternatives.

European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment

To develop a European guideline on pharmacologic treatment of Tourette syndrome (TS) the available literature was thoroughly screened and extensively discussed by a working group of the European Society for the Study of Tourette syndrome (ESSTS). Although there are many more studies on pharmacotherapy of TS than on behavioral treatment options, only a limited number of studies meets rigorous quality criteria. Therefore, we have devised a two-stage approach. First, we present the highest level of evidence by reporting the findings of existing Cochrane reviews in this field. Subsequently, we provide the first comprehensive overview of all reports on pharmacological treatment options for TS through a MEDLINE, PubMed, and EMBASE search for all studies that document the effect of pharmacological treatment of TS and other tic disorders between 1970 and November 2010. We present a summary of the current consensus on pharmacological treatment options for TS in Europe to guide the clinician in daily practice. This summary is, however, rather a status quo of a clinically helpful but merely low evidence guideline, mainly driven by expert experience and opinion, since rigorous experimental studies are scarce.

Treatment strategies for tics in Tourette syndrome

TOURETTE SYNDROME (TS) IS A CHRONIC NEURODEVELOPMENTAL DISORDER CHARACTERIZED BY TICS: repetitive, involuntary movements and vocalizations. These symptoms can have a significant impact on patients' daily functioning across many domains. Tics tend to be most severe in child and adolescent sufferers, so their presence has the potential to impact a period of life that is both critical for learning and is often associated with the experience of greater social tension and self-consciousness than adulthood. Furthermore, control over tics that lead to physical impairment or self-injurious behaviour is of vital importance in maintaining health and quality of life. There are numerous complicating factors in the prescription of treatment for tics, due to both the side effects associated with alleviating agents and patient characteristics, such as age and comorbid conditions. This review summarizes literature pertaining to the efficacy and safety of both traditionally prescribed and more modern medications. We also discuss the merits of behavioural and surgical techniques and highlight newer emerging treatments. Although treatment response is to some extent variable, there are a number of agents that are clearly useful as first-line treatments for TS. Other interventions may be of most benefit to patients exhibiting refractory tics or more specific symptom profiles.

Behavioral interventions for tic disorders

A variety of treatment approaches have been used to manage tic symptoms in Tourette syndrome and other tic disorders. Pharmacological interventions remain the most common approach, but in the past 3 decades, various nonpharmacological treatment options have emerged including: (1) massed practice, (2) relaxation training, (3) self-monitoring, (4) function-based/contingency management procedures, (5) habit reversal training, (6) exposure and response prevention, and (7) cognitive behavior therapy. Each of these procedures is described along with the evidence reflecting its efficacy and usefulness. A synthesis of the findings and implications is provided, including directions and recommendations for future treatment and research.

Behavior therapy for children with Tourette disorder: a randomized controlled trial

CONTEXT

Tourette disorder is a chronic and typically impairing childhood-onset neurologic condition. Antipsychotic medications, the first-line treatments for moderate to severe tics, are often associated with adverse effects. Behavioral interventions, although promising, have not been evaluated in large-scale controlled trials.

OBJECTIVE

To determine the efficacy of a comprehensive behavioral intervention for reducing tic severity in children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, observer-blind, controlled trial of 126 children recruited from December 2004 through May 2007 and aged 9 through 17 years, with impairing Tourette or chronic tic disorder as a primary diagnosis, randomly assigned to 8 sessions during 10 weeks of behavior therapy (n = 61) or a control treatment consisting of supportive therapy and education (n = 65). Responders received 3 monthly booster treatment sessions and were reassessed at 3 and 6 months following treatment.

INTERVENTION

Comprehensive behavioral intervention.

MAIN OUTCOME MEASURES

Yale Global Tic Severity Scale (range 0-50, score >15 indicating clinically significant tics) and Clinical Global Impressions-Improvement Scale (range 1 [very much improved] to 8 [very much worse]).

RESULTS

Behavioral intervention led to a significantly greater decrease on the Yale Global Tic Severity Scale (24.7 [95% confidence interval {CI}, 23.1-26.3] to 17.1 [95% CI, 15.1-19.1]) from baseline to end point compared with the control treatment (24.6 [95% CI, 23.2-26.0] to 21.1 [95% CI, 19.2-23.0]) (P < .001; difference between groups, 4.1; 95% CI, 2.0-6.2) (effect size = 0.68). Significantly more children receiving behavioral intervention compared with those in the control group were rated as being very much improved or much improved on the Clinical Global Impressions-Improvement scale (52.5% vs 18.5%, respectively; P < .001; number needed to treat = 3). Attrition was low (12/126, or 9.5%); tic worsening was reported by 4% of children (5/126). Treatment gains were durable, with 87% of available responders to behavior therapy exhibiting continued benefit 6 months following treatment.

CONCLUSION

A comprehensive behavioral intervention, compared with supportive therapy and education, resulted in greater improvement in symptom severity among children with Tourette and chronic tic disorder.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00218777.

Cannabinoids for Tourette's Syndrome

BACKGROUND

Gilles de la Tourette Syndrome (GTS) is a developmental neuropsychiatric disorder characterised by the presence of chronic motor and phonic tics. Drugs currently used in the treatment of GTS either lack efficacy or are associated with intolerable side effects. There is some anecdotal and experimental evidence that cannabinoids may be effective in treating tics and compulsive behaviour in patients with GTS. There are currently no systematic Cochrane reviews of treatments used in GTS. There is one other Cochrane review being undertaken at present, on the use of fluoxetine for tics in GTS.

OBJECTIVES

To evaluate the efficacy and safety of cannabinoids as compared to placebo or other drugs in treating tics, premonitory urges and obsessive compulsive symptoms (OCS), in patients with GTS.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (in The Cochrane Library Issue 4 2008) , MEDLINE (January 1996 to date), EMBASE (January 1974 to date), PsycINFO (January 1887 to date), CINAHL (January 1982 to date), AMED (January 1985 to date), British Nursing Index (January 1994 to date) and DH DATA (January 1994 to date). We also searched the reference lists of located trials and review articles for further information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any cannabinoid preparation with placebo or other drugs used in the treatment of tics and OCS in patients with GTS.

DATA COLLECTION AND ANALYSIS

Two authors abstracted data independently and settled any differences by discussion.

MAIN RESULTS

Only two trials were found that met the inclusion criteria. Both compared a cannabinoid, delta-9-Tetrahydrocannabinol (Delta(9)THC), either as monotherapy or as adjuvant therapy, with placebo. One was a double blind, single dose crossover trial and the other was a double blind, parallel group study. A total of 28 different patients were studied. Although both trials reported a positive effect from Delta(9)THC, the improvements in tic frequency and severity were small and were only detected by some of the outcome measures.

AUTHORS' CONCLUSIONS

Not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome.

Cognitive–Behavioral and Psychopharmacological Treatment of Delusional Symptoms: A Preliminary Report

Several psychopathological conditions include delusional beliefs as central symptoms. A conceptual model highlighting the importance of cognitive factors in regulating the bizarre internal contingencies which characterize delusional systems is presented. Cognitive–behavioral treatment emphasizes the direct modification of expectations and beliefs as well as the disordered behavior patterns they support. The efficacy of neuroleptics in treating delusional states has also been reported. Two patients with predominate delusional beliefs were treated in a cross-over design by the sequential use of cognitive–behavior therapy and pimozide. A third patient received cognitive–behavioral training alone. The delusions as well as the anxiety associated with them diminished and behavioral functioning improved significantly following cognitive therapy. The relationship between delusional symptoms, perceptions of self, and social functioning, as well as the optimal application of cognitive–behavioral and psychopharmacological interventions are discussed.

Using prepulse inhibition to detect functional D3 receptor antagonism: effects of WC10 and WC44

Prepulse inhibition of startle (PPI) is an operational measure of sensorimotor gating that is impaired in schizophrenia. Treatment with mixed dopamine D2/D3 antagonists diminishes schizophrenia symptoms, and opposes dopamine agonist-induced PPI deficits in rats. There are reasons to believe that functional D3 receptor antagonists might offer more favorable therapeutic profiles compared to current antipsychotics. However, D3-related drug discovery is hampered by the absence of assays sensitive to D3-mediated (antipsychotic) properties in vivo. Here, we characterized two putative D3-active compounds - WC10 and WC44 - in a PPI-based screening assay, comparing the sensitivity of test compounds to oppose PPI deficits induced by the mixed D1/D2-like agonist apomorphine vs. the preferential D3 agonist pramipexole in rats. WC10, WC44 (0, 1, 3, 10 mg/kg, each), and the preferential D2 antagonist L741,626 (0, 1 mg/kg) were studied, in combination with apomorphine (0, 0.5 mg/kg), or pramipexole (0, 1 mg/kg). L741,626 prevented apomorphine-, but not pramipexole-induced PPI deficits. WC10, but not WC44, prevented apomorphine-induced PPI deficits; both compounds opposed pramipexole-induced PPI deficits, suggesting functional D3 and D1/D2 antagonist profiles for WC10, and functional D3 receptor antagonism for WC44. This assay may be valuable for detecting predominantly D3 vs. D2 receptor-linked mechanisms of action in vivo.

Pimozide for tics in Tourette's syndrome

BACKGROUND

Neuroleptic drugs with potent D-2 receptor blocking properties have been the traditional treatment for tics caused by Tourette Syndrome. Pimozide is the most studied of these. Use of these medications is declining because of concerns about side effects, and new atypical neuroleptics are now available. The true benefit and risks associated with pimozide compared to other drugs is not known.

OBJECTIVES

To evaluate the efficacy and harms of pimozide in comparison to placebo or other medications in the treatment of tics in Tourette Syndrome.

SEARCH STRATEGY

We cross-referenced pimozide and its proprietary names with Tourette Syndrome and its derivations, as MeSH headings and as text words, and searched the Cochrane Movement Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), MEDLINE (1950-April 2007), and EMBASE (1980-April 2007). Reference lists of relevant articles were reviewed for additional trials.

SELECTION CRITERIA

All randomized, controlled, double blind studies comparing pimozide to placebo or other medications for the treatment of tics in Tourette Syndrome were considered for inclusion in this review. Both parallel group and crossover studies of children or adults, at any dose and for any duration, were included.

DATA COLLECTION AND ANALYSIS

Data was abstracted independently by two authors onto standardized forms and disagreements were resolved by discussion.

MAIN RESULTS

Six randomized controlled trials were included (total 162 participants, age range 7 to 53 years). Pimozide was compared with: placebo and haloperidol (two trials), placebo (one trial), haloperidol (one trial), and risperidone (two trials). Methodological quality was rated 'fair' for all studies. Studies used different outcome measurement scales for assessing tic severity and adverse effects. Significant clinical heterogeneity made meta-analysis inappropriate. Pimozide was superior to placebo in three studies, though it caused more side effects than placebo in one of these. Pimozide was inferior to haloperidol in one of three studies (the other two showed no significant difference between the drugs), which also showed significantly fewer side effects associated with pimozide. No significant differences between pimozide and risperidone were detected.

AUTHORS' CONCLUSIONS

Pimozide is an effective treatment for tics in Tourette Syndrome, though the number of trials comparing its effect to placebo and other drugs is limited. Trials of longer duration (minimum six months) are needed to investigate the longer-term effects of pimozide compared to atypical neuroleptics. Future trials should use the Yale Global Tic Severity Scale to assess the main outcome measure, and quantify adverse events with the Extrapyramidal Symptoms Rating Scale.

Emerging treatments for Tourette's disorder

Tourette's disorder is a childhood-onset neuropsychiatric disorder characterized by multiple motor and vocal tics. Many children with Tourette's disorder improve throughout adolescence. However, some adults with Tourette's disorder still experience severe symptoms and significant disability. This article examines the evidence base for current treatments for Tourette's disorder. Emerging treatments such as deep brain stimulation, habit reversal therapy, and repetitive trans-cranial magnetic stimulation are also discussed.

Contemporary assessment and pharmacotherapy of Tourette syndrome

To develop a guide to clinical assessment and pharmacotherapy for children and adults with Tourette syndrome (TS), we reviewed published literature over the past 25 years to identify original articles and reviews on the assessment and pharmacological treatment of Tourette syndrome, attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). The literature search also included a survey of reviews published in book chapters. The assessment section was compiled from several reviews. Pharmacological treatments were classified into those with strong empirical support (as evidenced by two positive placebo-controlled studies for tics, OCD, or ADHD in TS samples); modest empirical support (one positive placebo-controlled study), or minimal support (open-label data only). We conclude that accurate diagnosis, including identification of comorbid conditions, is an essential step toward appropriate treatment for patients with TS. In many patients with TS, symptom management requires pharmacotherapy for tics or coexisting conditions. The evidence supporting efficacy and safety for medications used in patients with TS varies. But this evidence offers the best guide to clinical practice.

Anesthetic management for cesarean delivery in a woman with Gilles de la Tourette’s syndrome

Gilles de la Tourette's syndrome is a chronic neuropsychiatric disorder with an early childhood onset featuring mainly motor and vocal tics. We present the anesthetic management for cesarean delivery of a 21-year-old pregnant woman with Tourette's syndrome. She had shrugging of the shoulders and sudden, jerky, repetitive, irregular movements of the hands. General anesthesia was given for cesarean delivery. A live male infant weighing 3130 g was delivered. Her perioperative course was uneventful. No complication was observed. The patient and baby were discharged on the 4th postoperative day. It was decided to prescribe haloperidol 5 mg per day after lactation. Anesthesiologists should remember that there are special considerations when managing anesthesia in patients with Tourette's syndrome. The motor tics may lead to technical difficulty in performing regional anesthesia and surgery. Therefore general anesthesia may be appropriate in order to prevent agitation or involuntary movements. If patient movement and agitation can be controlled by sedation, regional block may be attempted. Drugs such as metoclopramide, ondansetron, midazolam and opioids may be used safely for anesthesia in Tourette's syndrome.

Emerging drugs in Tourette syndrome

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.