Tourette's Disorder

Tourette's Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with Tourette's disorder needs to meet all of the following criteria:

  • Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.)

  • The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.

  • Onset is before age 18 years.

  • The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington's disease, postviral encephalitis).
This disorder is characterized by both multiple motor and one or more vocal tics that have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.) The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months. The onset is before age 18 years. By early adulthood, only approximately 20% of patients will still have moderately debilitating tics, with most having mild tics or even remittance of their symptoms. This disorder is not due to a drug, medication or general medical condition. It is very important to educate teachers, family, and peers regarding the symptoms and natural course of this disorder. Obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD) frequently accompany this disorder, and require treatment in addition to the tic management. 

Effective Therapies

First-line treatment for mild-to-moderate tics is with an alpha-2 agonist (e.g., clonidine and guanfacine) or a benzodiazepine (e.g., clonazepam). OnabotulinumtoxinA (formerly known as botulinum toxin type A) injections may be considered when first-line treatment fails to improve mild-to-moderate tics. Individuals with severe tics that are refractory to first- and second-line therapy should be treated with neuroleptics or tetrabenazine. Out of the neuroleptics, risperidone is the preferable choice, followed by aripiprazole, ziprasidone, olanzapine, quetiapine, and the typical neuroleptics haloperidol and pimozide. Associated ADHD can effectively be treated with low-dose CNS stimulants (dextroamphetamine, levoamphetamine, and methylphenidate), or alpha-adrenergic agents (clonidine and guanfacine). Unfortunately, CNS stimulants sometimes increase tic disorder. Cognitive behavioral therapy (CBT) [exposure and response prevention] is a first-line treatment for any associated OCD. Second-line treatments for associated OCD are SSRI antidepressants and clomipramine. Medications can be tapered when the patient is experiencing fewer symptoms (e.g., on summer vacation).
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