Tic disorders/Tourette’s syndrome

When two or more different treatments are used concomitantly, it may be of interest to study in the same experiment both the effects due to each treatment (main effects) and the possible interaction between them (interaction effect). Interaction here means that the effect of one treatment is modified (e.g., decreased or enhanced) by the coadministration of the other treatment. In these cases, a factorial design can be considered. This design has been used, for instance to study the effects of clomidine and methylphenidate administered separately or in combination to children with ADHD and tic disorders (Tourette s Syndrome Study Group 2002). The simplest form is the 2x2... 

Stimulants should be initiated at recommended starting doses and titrated up with a consistent dosing schedule to the appropriate response while minimizing side effects (Table 39-2). Generally, stimulants should not be used in patients who have glaucoma, severe hypertension or cardiovascular disease, hyperthyroidism, severe anxiety, or previous illicit or stimulant drug abuse. Further, stimulants can be used, albeit cautiously, in patients with seizure disorders, Tourette s syndrome, and motor tics.14... 

Hauser RA, Zesiewicz TA. Sertraline-induced exacerbation of tics in Tourette s syndrome. Mov Disord 1995 10(5) 682-4. 

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

One exception is the patient with both ADHD and tic disorders such as Tourette s syndrome. High potency antipsychotics have proved quite effective in treating both vocal and motor tics. 

Tourette s syndrome, a heterogeneous behavioral disorder associated with motor and vocal tics of variable form and severity, can be effectively treated with haloperidol. Antipsychotics can also be employed to control disturbed behavior in senile dementia or Alzheimer s disease, since they decrease confusion, agitation, and hyperactivity. Most of these drugs also exhibit a strong antiemetic effect and can sometimes be used clinically for this purpose. 

In addition to tics, individuals with tic disorders may present with a broad array of behavioral difficulties including disinhibited speech or conduct, im-pulsivity, distractibility, motoric hyperactivity, and obsessive-compulsive symptoms (Leckman and Cohen, 1998). Alternatively, a sizable portion of children and adolescents with tics will be free of coexisting developmental or emotional difficulties. Scientific opinion has been divided on how broadly to conceive the spectrum of maladaptive behaviors associated with Tourette s syndrome (TS) (Comings, 1988 Shapiro et al., 1988). 

Tourette s Syndrome is a familial disorder (Pauls et ah, 1991 Walkup et ah, 1996). Twin and family studies provide evidence that genetic factors are involved in the vertical transmission within families of a vulnerability to TS and related disorders. The concordance rate for TS among monozygotic twin pairs is 50% while the concordance of dizygotic twin pairs is about 10% (Price et ah, 1985). If co-twins with chronic motor tic... 

King, R.A., Leckman, J.E, Scahill, L.D., and Cohen, D.J. (1998) Obsessive-compulsive disorder, anxiety and depression. In Leckman, J.E. and Cohen, D.J., eds. Tourette s Syndrome Tics, Obsessions, Compulsions—Developmental—Psychopathology and Clinical Care. New York John Wiley and Sons, pp. 43-62. 

Spencer, T. Biederman, J., Wilens, X Steingard, R., Geist, D. (1993b) Nortriptyline in the treatment of children with attention deficit hyperactivity disorder and tic disorder or Tourette s syndrome. Am Acad Child Adolesc Psychiatry 32 205—210. 

Tourette s syndrome is a well-studied condition, characterized by motor and phonic tics and by behavioral and psychological problems. While many neurotransmitters were implicated in the etiology of this disorder, it is now believed that the dopaminergic system and noradrenergic systems are involved. Two major clinical trials (Shapiro et ah, 1989 Sallee et al, 1997) indicated that haloperidol and pimozide reduced the severity of tics by 65%. However, these medications are associated with side effects (including possible cognitive impairment, sedation, dysphoria, and tardive dyskinesia) that may limit their effectiveness in children with MR. 

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