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

Tics

Tics are very common in children. They are often present for a limited period of time (transient tics) and typically remit or significantly improve before adulthood. The majority of people with tics don’t seek medical attention. The prototypical tic disorder causing disability is Gilles de la Tourette syndrome (TS), a childhood onset neuropsychiatric disorder predominantly characterised by fluctuating and persisting motor and phonic tics but also a wide array of complex symptoms, such as premonitory urges, echo- and coprophenomena and a variety of comorbidities including attention deficit hyperactivity disorder (ADHD), and obsessive compulsive disorder (OCD). The most conspicuous feature distinguishing TS from other movement disorders are preceding inner urges, hence tics are often experienced as voluntary movements, performed to transiently relieve unpleasant premonitory sensations. A typical course in a TS patient would be the onset of motor tics around the age of 5, onset of vocal tics several months or a few years later, with a peak of symptoms between the ages of 8 and 12 and a marked decrease until early adulthood. Aetiology is largely genetic with environmental factors probably playing a disease-modifying role. There is much overlap with OCD and ADHD both phenomenologically and genetically, but specific mutations have not been identified. Structural and functional differences in brain areas between TS patients and healthy controls predominantly point to a dysfunction of the basal ganglia (BG) with an imbalance in the dopaminergic system. In line with these findings, the most successful treatment options in TS encompass typical and atypical antipsychotics. Some patients also benefit from tetrahydrocannabinol (THC), botulinum toxin injections or, rarely, deep brain stimulation. Behavioural treatment has also been promoted. However, tics wax and wane and naturally decrease in 80% of TS patients after puberty. Moreover, patients commonly suffer more from comorbidities than from TS. Therefore, most patients do not require pharmacological treatment for tics but can benefit from psychoeducation