Keywords
1. Tourette syndrome treatment
2. Chronic tic disorder therapy
3. Deep brain stimulation Tourette’s
4. Comprehensive Behavioral Intervention for Tics (CBIT)
5. Antipsychotic medication tics
In an extensive and exhaustive systematic review published in Neurology, the official journal of the American Academy of Neurology, the current state of treatments for tics in individuals with Tourette syndrome and chronic tic disorders has been thoroughly analyzed. “Comprehensive systematic review summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders” reflects a significant scientific endeavor to synthesize and evaluate the efficacy and risks associated with a wide range of interventions, from pharmacological treatments to neurostimulation techniques. In this article, we delve into the findings presented by Pringsheim and colleagues (Pringsheim, T., Holler-Managan, Y., Okun, M.S., et al., 2019), and discuss the implications for medical practice and patient care.
Introduction
Tourette syndrome is a neurological disorder characterized by repetitive, involuntary movements and vocalizations known as tics. Affecting both adults and children, the condition can lead to significant distress and impact on quality of life, necessitating effective treatment strategies. Chronic tic disorders are similarly disruptive and often demand a thorough and careful approach to management (American Psychiatric Association, DSM-5 Task Force, 2013).
Methodology
The review conducted by Pringsheim et al. (2019) adhered to the rigorous standards outlined in the 2011 edition of the American Academy of Neurology’s guideline development process manual. The team of experts included systematic reviews and randomized controlled trials concerning at least 20 participants—or 10 in the case of crossover trials—with no minimum sample size required for neurostimulation trials. In addition to this, cohort studies or case series that specifically assessed adverse drug effects in individuals with tics were also considered, providing a well-rounded understanding of both the benefits and the potential harms of each intervention.
Efficacy of Treatments
One of the key findings of the review is the demonstrated efficacy of Comprehensive Behavioral Intervention for Tics (CBIT), which yielded higher confidence in tic reduction compared to psychoeducation and supportive therapy. Several medications, including haloperidol, risperidone, aripiprazole, tiapride, clonidine, and interventions like onabotulinumtoxinA injections, showed moderate confidence in reducing tics compared to placebo. Furthermore, deep brain stimulation of the globus pallidus was highlighted as a promising therapeutic avenue, especially for severe cases that are refractory to other treatments.
Chinese herbal medicines like 5-ling granule and Ningdong granule also exhibited moderate confidence in efficacy, suggesting the valuable role of alternative treatments in certain contexts (Wang et al., 2012; Zhao et al., 2010).
Interestingly, treatments such as pimozide, ziprasidone, metoclopramide, guanfacine, topiramate, and tetrahydrocannabinol were classified as having low confidence levels in their potential to reduce tics when compared to placebo, highlighting the necessity for further study and cautious application.
Risks and Adverse Effects
No treatment comes without risk, and prudent medical care requires a balancing act between benefits and potential harms. The review drew attention to the array of adverse effects associated with tic treatments. Weight gain, drug-induced movement disorders, elevated prolactin levels, sedation, along with cardiovascular impacts on heart rate, blood pressure, and ECGs, were all documented as possible complications of the various therapeutic options (Pringsheim et al., 2019).
Discussion
The extensive systematic review provides a critical resource for clinicians treating Tourette syndrome and chronic tic disorders. Despite the availability of various interventions, it is clear that treatment must be individualized, taking into account the specific circumstances and health profile of each patient.
CBIT emerges from the study as a highly regarded non-pharmacological behavioral treatment, which, because of its minimal side effects, may be particularly appealing for patients and their families (Piacentini et al., 2010; Wilhelm et al., 2012).
Deep brain stimulation, a more invasive procedure reserved typically for the most debilitating cases, demonstrates the ongoing progress and innovation in treating neurological disorders. Its inclusion in the study reiterates its potential as a life-changing intervention for those with severe tics unresponsive to conventional therapies (Kefalopoulou et al., 2015).
Medication remains a cornerstone in tic management, but the systematic review urges caution, particularly in pediatric populations where the balance of risk to benefit must be closely evaluated. This review serves as a strong reminder of the critical importance of a personalized approach, echoing calls for continued research in the area to optimize treatment strategies and mitigate adverse effects.
Conclusion
Pringsheim et al. (2019) provide a seminal work with their rigorous evaluation of the treatment landscape for Tourette syndrome and chronic tic disorders. Clinicians and patients alike stand to benefit from the insights and assessment of confidence in both the beneficial and harmful aspects of a wide array of therapeutic interventions. While promising strategies have been identified, the study underscores the ongoing need for vigilant, personalized, and evidence-based medical care in this field.
The increasing body of research into Tourette syndrome and chronic tic disorders epitomizes the intersection of complexity and progress in neurology. As the scientific community continues to build upon this solid foundation, future patients may look forward to a landscape of ever more refined and effective treatments, with the ultimate goal of uplifting the quality of life for those afflicted by these challenging conditions.
References
1. Pringsheim, T., Holler-Managan, Y., Okun, M.S., et al. (2019). Comprehensive systematic review summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 907-915. doi:10.1212/WNL.0000000000007467
2. American Psychiatric Association, DSM-5 Task Force. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5™, 5th ed. Arlington: American Psychiatric Publishing.
3. Wang, S., Qi, F., Li, J., Zhao, L., Li, A. (2012). Effects of Chinese herbal medicine Ningdong granule on regulating dopamine (DA)/serotonin (5-HT) and gamma-amino butyric acid (GABA) in patients with Tourette syndrome. Biosci Trends, 6, 212-218.
4. Zhao, L., Li, A.Y., Lv, H., Liu, F.Y., Qi, F.H. (2010). Traditional Chinese medicine Ningdong granule: the beneficial effects in Tourette’s disorder. J Int Med Res, 38, 169-175.
5. Piacentini, J., Woods, D.W., Scahill, L., et al. (2010). Behavior therapy for children with Tourette disorder: a randomized controlled trial. JAMA, 303, 1929-1937. doi:10.1001/jama.2010.607
6. Wilhelm, S., Peterson, A.L., Piacentini, J., et al. (2012). Randomized trial of behavior therapy for adults with Tourette syndrome. Arch Gen Psychiatry, 69, 795-803. doi:10.1001/archgenpsychiatry.2011.1528
7. Kefalopoulou, Z., Zrinzo, L., Jahanshahi, M., et al. (2015). Bilateral globus pallidus stimulation for severe Tourette’s syndrome: a double-blind, randomised crossover trial. Lancet Neurol, 14, 595-605. doi:10.1016/S1474-4422(15)00008-3