The American Academy of Neurology has released new guidelines for tic disorders and tics in Tourette’s syndrome. The guideline is endorsed by the Child Neurology Society and the European Academy of Neurology and published in the May 7 issue of Neurology. This is the first published evidence-based guideline for neurologists published.
The guideline emphasizes that a thorough diagnostic work up is needed in all patients with tics. Special attention should be paid to ruling out or identifying obsessive-compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), and anxiety, all of which are frequent comorbidities of tics that can be treated. It is essential to identify and treat OCD, ADHD, and anxiety in a person with tics and treat as needed. Left untreated, OCD, ADHD, and anxiety can interfere with successful treatment of tics. It is also recommended that neurologists provide education to people with tics and their family that there is a good chance that tics will resolve in late adolescence.
“Tourette syndrome and other chronic tic disorders can be of great concern to the person diagnosed and their family, so it is important that doctors let those affected know that tics may improve with time,” said guideline lead author Tamara Pringsheim, MD, MSc, of the University of Calgary in Alberta, Canada, and a Fellow of the American Academy of Neurology. “Treatments can help decrease tic frequency and severity, but they rarely eliminate all tics. It is important that people are informed of all the available treatment options, which include education, behavioral therapies, medication, or watchful waiting.”
When treatment of tics is needed, the guideline recommends Comprehensive Behavioral Intervention for Tics (CBIT), which is a process of learning skills and behavior proven effective to help people control the urges that lead to tics. Relaxation therapy, habit-reversal training, and behavior therapy over a 10-12-week period are components of CBIT.
When medications are needed, alpha-adrenergic agonists can be used and improve both tics and any comorbid ADHD. When benefits outweigh risks, antipsychotic medications can be considered, but must be used with care, titrating the dose and educating patients not to stop taking medication without physician supervision and tapering to prevent dyskinesia.
There is limited evidence that treatment with botulinum toxin may be helpful for people in their late teen years or adults. Adults with severe tics may benefit from deep-brain stimulation. The guideline notes that some adults with tics self-treat with Cannabis. In states where medical marijuana is legal, it is recommended that physicians educate patients about the variability in dose and strength that is inherent to medical marijuana and direct them to physicians who can supervise that use.
Peter McAllister, MD
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