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Baizabal-Carvallo JF, Cavanna AE, Jankovic J. Tics emergencies and malignant tourette syndrome: Assessment and management. Neurosci Biobehav Rev 2024; 159:105609. [PMID: 38447821 DOI: 10.1016/j.neubiorev.2024.105609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/29/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
Tourette syndrome (TS) is a complex neurodevelopmental disorder characterized by the presence of tics, frequently accompanied by a variety of neuropsychiatric comorbidities. A subset of patients with TS present with severe and disabling symptoms, requiring prompt therapeutic intervention. Some of these manifestations may result in medical emergencies when severe motor or phonic tics lead to damage of anatomical structures closely related to the tic. Examples include myelopathy or radiculopathy following severe neck ("whiplash") jerks or a variety of self-inflicted injuries. In addition to self-aggression or, less commonly, allo-aggression, some patients exhibit highly inappropriate behavior, suicidal tendencies, and rage attacks which increase the burden of the disease and are important components of "malignant TS". This subset of TS is frequently associated with comorbid obsessive-compulsive disorder. Therapeutic measures include intensive behavioral therapy, optimization of oral pharmacotherapy, botulinum toxin injections, and deep brain stimulation.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA; Department of Sciences and Engineering, University of Guanajuato, León, Mexico.
| | - Andrea E Cavanna
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom; Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and University College London, London, United Kingdom; School of Health and Life Sciences, Aston Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom; School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
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Schütteler C, Gerlach AL. Die Bedeutung des Vorgefühls bei Tic-Störungen. ZEITSCHRIFT FUR KLINISCHE PSYCHOLOGIE UND PSYCHOTHERAPIE 2022. [DOI: 10.1026/1616-3443/a000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Zusammenfassung. Theoretischer Hintergrund: Die Funktion des Vorgefühls in der Pathogenese und Aufrechterhaltung von Tic-Störungen (TS) wird in den letzten Jahren verstärkt erforscht. Die mögliche funktionelle Bedeutung der Vorgefühle wird aber noch nicht ausreichend verstanden. Methode: Im vorliegenden Review wird der Kenntnisstand zu Vorgefühlen entlang eines integrativen funktionalen Störungsmodells zusammengefasst. Ergebnisse: Im Vergleich zum Jugendalter nehmen Tic-Symptome bei Tic-Störungen im Erwachsenenalter ab, während immer mehr Betroffene ein Vorgefühl berichten. Hierbei kann zwischen einem allgemeinen Vorgefühl (trait) und dem Drang, Tics auszuführen (state) unterschieden werden. Das Vorgefühl als trait ist abhängig von der Interozeptionsfähigkeit. An den Drang, Tics auszuführen, kann habituiert werden, moderiert von Aufmerksamkeits- und Attributionsprozessen. Durch das Auflösen des Vorgefühl-Tic-Reizreaktionsmusters reduzieren sich die Tic-Symptome. Schlussfolgerung: Für weitere Erkenntnisse in Bezug auf die Bedeutung von Vorgefühl und den Drang, Tics auszuführen, sollten zukünftige Forschungsansätze Drang und allgemeine Vorgefühle in therapeutischen Interventionsstudien berücksichtigen, weitere Interozeptionsparadigmen einbeziehen und die Entwicklung von allgemeinem Vorgefühl und Drang über die Lebensspanne hinweg untersuchen.
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Affiliation(s)
- Christina Schütteler
- Institut für Klinische Psychologie und Psychotherapie, Universität zu Köln, Deutschland
| | - Alexander L. Gerlach
- Institut für Klinische Psychologie und Psychotherapie, Universität zu Köln, Deutschland
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Frey J, Malaty IA. Tourette Syndrome Treatment Updates: a Review and Discussion of the Current and Upcoming Literature. Curr Neurol Neurosci Rep 2022; 22:123-142. [PMID: 35107785 PMCID: PMC8809236 DOI: 10.1007/s11910-022-01177-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 11/30/2022]
Abstract
Purpose of Review This study aims to examine the treatments currently available for Tourette syndrome (TS) and to discuss evolving therapies, spanning behavioral, pharmacologic, complementary and alternative medicine, and neuromodulation approaches. Recent Findings Behavioral therapies have undergone several modifications to improve accessibility, including transitioning to a virtual format which is particularly important in the current pandemic. There are several recent or ongoing pharmacologic studies that have shown promise including the selective D1 receptor antagonist ecopipam and various cannabinoid compounds. Adaptive DBS may enable the physiologic markers of tics to determine stimulation parameters and improve tic outcomes related to neuromodulation. Summary In recent years, there has been a wealth of research across multiple treatment domains in the TS field. This review highlights exciting and new potential options for the future treatment of patients with TS.
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Affiliation(s)
- Jessica Frey
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Irene A Malaty
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
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Anandan C, Jankovic J. Botulinum Toxin in Movement Disorders: An Update. Toxins (Basel) 2021; 13:toxins13010042. [PMID: 33430071 PMCID: PMC7827923 DOI: 10.3390/toxins13010042] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 12/17/2022] Open
Abstract
Since its initial approval in 1989 by the US Food and Drug Administration for the treatment of blepharospasm and other facial spasms, botulinum toxin (BoNT) has evolved into a therapeutic modality for a variety of neurological and non-neurological disorders. With respect to neurologic movement disorders, BoNT has been reported to be effective for the treatment of dystonia, bruxism, tremors, tics, myoclonus, restless legs syndrome, tardive dyskinesia, and a variety of symptoms associated with Parkinson’s disease. More recently, research with BoNT has expanded beyond its use as a powerful muscle relaxant and a peripherally active drug to its potential central nervous system applications in the treatment of neurodegenerative disorders. Although BoNT is the most potent biologic toxin, when it is administered by knowledgeable and experienced clinicians, it is one of the safest therapeutic agents in clinical use. The primary aim of this article is to provide an update on recent advances in BoNT research with a focus on novel applications in the treatment of movement disorders. This comprehensive review of the literature provides a critical review of evidence-based clinical trials and highlights recent innovative pilot studies.
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Abstract
Tourette syndrome is a complex neuropsychiatric disorder with a wide phenotypic spectrum, including tics and psychiatric comorbidities, such as obsessive-compulsive disorder and attention-deficit disorder. Often considered a neurodevelopmental disorder, it is most prevalent during childhood and treatment strategies can vary according to degree of severity and patient-specific symptom manifestations. This review focuses on established and emerging management options for tics, including behavioral interventions and nonpharmacologic therapies, medication management, and promising surgical approaches.
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Affiliation(s)
- Joohi Jimenez-Shahed
- Movement Disorders Neuromodulation & Brain Circuit Therapeutics, Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai West, 1000 10th Avenue, Suite 10C, New York, NY 10019, USA.
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Jankovic J. Treatment of tics associated with Tourette syndrome. J Neural Transm (Vienna) 2020; 127:843-850. [PMID: 31955299 DOI: 10.1007/s00702-019-02105-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/14/2019] [Indexed: 01/04/2023]
Abstract
Motor and phonic tics associated with Tourette syndrome (TS) can range in severity from barely perceptible to disabling and most patients have a variety of behavioral co-morbidities, particularly, attention deficit disorder and obsessive compulsive disorder. Therefore, therapy must be tailored to the individual needs of the patients. In addition to behavioral therapy, oral medications such as alpha agonists, dopamine depletors, anti-psychotics, and topiramate are used to control the involuntary movements and noises. Botulinum toxin injections are particularly effective in patients with troublesome focal motor and phonic tics, including coprolalia. Deep brain stimulation may be considered for patients with "malignant" TS, that is, refractory to medical therapy. When appropriate therapy is selected and implemented, most patients with TS can achieve their full potential and lead essentially normal life.
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Affiliation(s)
- Joseph Jankovic
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, 7200 Cambridge, Suite 9A, Houston, TX, 77030-4202, USA.
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Pandey S, Dash D. Progress in Pharmacological and Surgical Management of Tourette Syndrome and Other Chronic Tic Disorders. Neurologist 2019; 24:93-108. [DOI: 10.1097/nrl.0000000000000218] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nam SH, Park J, Park TW. Clinical Aspects of Premonitory Urges in Patients with Tourette's Disorder. Soa Chongsonyon Chongsin Uihak 2019; 30:50-56. [PMID: 32595321 PMCID: PMC7289498 DOI: 10.5765/jkacap.180025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/12/2018] [Accepted: 12/06/2018] [Indexed: 11/06/2022] Open
Abstract
Most patients with Tourette’s disorder experience an uncomfortable sensory phenomenon called the premonitory urge immediately before experiencing tics. It has been suggested that premonitory urges are associated with comorbidities such as obsessive compulsive disorder, anxiety disorders, and attention-deficit/hyperactivity disorder, although these associations have been inconsistent. Most patients experience tics as a result of the premonitory urges, and after the tics occur, most patients report that the premonitory urges are temporarily relieved. As a consequence, several studies have assessed the premonitory urge and its potential therapeutic utility. Based on the concept that the premonitory urge induces tics, behavioral treatments such as Exposure and Response Prevention and Habit Reversal Therapy have been developed. However, it is still unclear whether habituation, the main mechanism of these therapies, is directly related to their effectiveness. Moreover, the observed effects of pharmacological treatments on premonitory urges have been inconsistent.
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Affiliation(s)
- Seok Hyun Nam
- Department of Psychiatry, College of Medicine, Chonbuk National University, Jeonju, Korea
| | - Juhyun Park
- College of Medicine, Seoul National University, Seoul, Korea
| | - Tae Won Park
- Department of Psychiatry, College of Medicine, Chonbuk National University, Jeonju, Korea.,Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
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Pandey S, Srivanitchapoom P, Kirubakaran R, Berman BD. Botulinum toxin for motor and phonic tics in Tourette's syndrome. Cochrane Database Syst Rev 2018; 1:CD012285. [PMID: 29304272 PMCID: PMC6491277 DOI: 10.1002/14651858.cd012285.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Gilles de la Tourette syndrome, or Tourette's syndrome, is defined as the presence of both motor and vocal (phonic) tics for more than 12 months, that manifest before the age of 18 years, in the absence of secondary causes. Treatment of motor and phonic tics is difficult and challenging. OBJECTIVES To determine the safety and effectiveness of botulinum toxin in treating motor and phonic tics in people with Tourette's syndrome, and to analyse the effect of botulinum toxin on premonitory urge and sensory tics. SEARCH METHODS We searched the Cochrane Movement Disorders Group Trials Register, CENTRAL, MEDLINE, and two trials registers to 25 October 2017. We reviewed reference lists of relevant articles for additional trials. SELECTION CRITERIA We considered all randomised, controlled, double-blind studies comparing botulinum toxin to placebo or other medications for the treatment of motor and phonic tics in Tourette's syndrome for this review. We sought both parallel group and cross-over studies of children or adults, at any dose, and for any duration. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods to select studies, assess risk of bias, extract and analyse data. All authors independently abstracted data onto standardized forms; disagreements were resolved by mutual discussion. MAIN RESULTS Only one randomised placebo-controlled, double-blind cross-over study met our selection criteria. In this study, 20 participants with motor tics were enrolled over a three-year recruitment period; 18 (14 of whom had a diagnosis of Tourette's syndrome) completed the study; in total, 21 focal motor tics were treated. Although we considered most bias domains to be at low risk of bias, the study recruited a small number of participants with relatively mild tics and provided limited data for our key outcomes. The effects of botulinum toxin injections on tic frequency, measured by videotape or rated subjectively, and on premonitory urge, are uncertain (very low-quality evidence). The quality of evidence for adverse events following botulinum toxin was very low. Nine people had muscle weakness following the injection, which could have led to unblinding of treatment group assignment. No data were available to evaluate whether botulinum injections led to immunoresistance to botulinum. AUTHORS' CONCLUSIONS We are uncertain about botulinum toxin effects in the treatment of focal motor and phonic tics in select cases, as we assessed the quality of the evidence as very low. Additional randomised controlled studies are needed to demonstrate the benefits and harms of botulinum toxin therapy for the treatment of motor and phonic tics in patients with Tourette's syndrome.
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Affiliation(s)
- Sanjay Pandey
- G.B. Pant HospitalDepartment of NeurologyNew DelhiIndia110002
| | - Prachaya Srivanitchapoom
- Siriraj Hospital, Mahidol UniversityDepartment of Medicine, Division of Neurology2 Prannok Road, Siriraj, Bangkok‐noiBangkokThailand10700
| | - Richard Kirubakaran
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Center for Evidence‐Informed Health Care and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Brian D Berman
- University of Colorado, School of MedicineDepartment of NeurologyAuroraColoradoUSA80045
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Malaty IA, Akbar U. Updates in medical and surgical therapies for Tourette syndrome. Curr Neurol Neurosci Rep 2014; 14:458. [PMID: 24871966 DOI: 10.1007/s11910-014-0458-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tourette syndrome is a complex neurobehavioral disorder defined by multiple motor and at least 1 vocal tic, persisting over 1 year, waxing and waning in severity, and not explained by another condition. The condition may range from mild nuisance to debilitating and disabling in severity. Management includes counseling and reassurance, behavioral interventions, pharmacologic, and rarely, surgical interventions. Traditionally, alpha-2 agonists and dopamine receptor antagonists have been utilized. In addition, a number of different pharmacotherapies have been implemented in the search for improved management of tics with better tolerability. In rare, severely disabling cases, neuromodulation with deep brain stimulation may be indicated. Optimal brain targets and candidate selection are still in evolution. This article will review the evidence for current medical and surgical therapies with a focus on recent updates.
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Affiliation(s)
- Irene A Malaty
- Department of Neurology, University of Florida, UF Center for Movement Disorders and Neurorestoration, P.O. Box 100236, Gainesville, FL, 32610, USA,
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Hartmann A. Clinical pharmacology of nondopaminergic drugs in Tourette syndrome. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2014; 112:351-72. [PMID: 24295626 DOI: 10.1016/b978-0-12-411546-0.00011-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Treatment of tics and Gilles de la Tourette syndrome (GTS) by nondopaminergic drugs was initiated more than three decades ago. These approaches were driven by the wish to circumvent antipsychotic-related side effects (metabolic disturbances, parkinsonian syndromes, tardive dyskinesia) or to use these treatments as a valuable add-on therapy in patients at least partially refractory to antipsychotics. In this review, we will therefore discuss the potential value of treating tics with alpha2 receptor agonists, nicotine, tetrabenazine, GABA agonists, botulinum toxin, cannabinoids, and immune modulators (plasmapheresis, intravenous immunoglobulins, antibiotic prophylaxis). Future directions for clinical trials based on our expanding understanding of the pathophysiology of GTS with regard to cholinergic, glutamatergic, and histaminergic neurotransmission will also be briefly outlined.
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Affiliation(s)
- Andreas Hartmann
- Centre de Référence National Maladie Rare: 'Syndrome Gilles de la Tourette', Département de Neurologie, Pôle des Maladies du Système Nerveux, Paris, France; Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière, UPMC/INSERM UMR_S975; CNRS UMR 7225, Paris, France.
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Abstract
Movement disorders, which include disorders such as Parkinson's disease, dystonia, Tourette's syndrome, restless legs syndrome, and akathisia, have traditionally been considered to be disorders of impaired motor control resulting predominantly from dysfunction of the basal ganglia. This notion has been revised largely because of increasing recognition of associated behavioural, psychiatric, autonomic, and other non-motor symptoms. The sensory aspects of movement disorders include intrinsic sensory abnormalities and the effects of external sensory input on the underlying motor abnormality. The basal ganglia, cerebellum, thalamus, and their connections, coupled with altered sensory input, seem to play a key part in abnormal sensorimotor integration. However, more investigation into the phenomenology and physiological basis of sensory abnormalities, and about the role of the basal ganglia, cerebellum, and related structures in somatosensory processing, and its effect on motor control, is needed.
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Affiliation(s)
- Neepa Patel
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA.
| | - Mark Hallett
- Human Motor Control Section, NINDS, National Institutes of Health, Bethesda, MD, USA
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Hyun JK, Lee JH, Lee CM, Lim MH. The Clinical Effect of Botulinum Toxin in a Patient with Tourette's Syndrome: A Case Report and Review. Soa Chongsonyon Chongsin Uihak 2013. [DOI: 10.5765/jkacap.2013.24.2.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Thenganatt MA, Fahn S. Botulinum toxin for the treatment of movement disorders. Curr Neurol Neurosci Rep 2012; 12:399-409. [PMID: 22661378 DOI: 10.1007/s11910-012-0286-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
After botulinum toxin was initially used to treat strabismus in the 1970s, others started using it to treat movement disorders including blepharospasm, hemifacial spasm, cervical dystonia, spasmodic dysphonia, and oromandibular dystonia. It was discovered that botulinum toxin can be an effective treatment for focal movement disorders with limited side effects. Over the past three decades, various formulations of botulinum toxin have been developed and the therapeutic use of these toxins has expanded in movement disorders and beyond. We review the history and mechanism of action of botulinum toxin, as well as describe different formulations available and their potential therapeutic uses in movement disorders.
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Affiliation(s)
- Mary Ann Thenganatt
- Department of Neurology, College of Physicians and Surgeons, Columbia University, 710 West 168th Street, New York, NY 10032, USA.
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Roessner V, Plessen KJ, Rothenberger A, Ludolph AG, Rizzo R, Skov L, Strand G, Stern JS, Termine C, Hoekstra PJ. European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment. Eur Child Adolesc Psychiatry 2011; 20:173-96. [PMID: 21445724 PMCID: PMC3065650 DOI: 10.1007/s00787-011-0163-7] [Citation(s) in RCA: 275] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Veit Roessner
- Department of Child and Adolescent Psychiatry, University of Dresden Medical School, Fetscherstrasse 74, 01307 Dresden, Germany.
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Gilles de la Tourette syndrome: the complexities of phenotype and treatment – further information. Br J Hosp Med (Lond) 2011. [DOI: 10.12968/hmed.2011.72.2.s1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Eddy CM, Rickards HE, Cavanna AE. Treatment strategies for tics in Tourette syndrome. Ther Adv Neurol Disord 2011; 4:25-45. [PMID: 21339906 PMCID: PMC3036957 DOI: 10.1177/1756285610390261] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
TOURETTE SYNDROME (TS) IS A CHRONIC NEURODEVELOPMENTAL DISORDER CHARACTERIZED BY TICS: repetitive, involuntary movements and vocalizations. These symptoms can have a significant impact on patients' daily functioning across many domains. Tics tend to be most severe in child and adolescent sufferers, so their presence has the potential to impact a period of life that is both critical for learning and is often associated with the experience of greater social tension and self-consciousness than adulthood. Furthermore, control over tics that lead to physical impairment or self-injurious behaviour is of vital importance in maintaining health and quality of life. There are numerous complicating factors in the prescription of treatment for tics, due to both the side effects associated with alleviating agents and patient characteristics, such as age and comorbid conditions. This review summarizes literature pertaining to the efficacy and safety of both traditionally prescribed and more modern medications. We also discuss the merits of behavioural and surgical techniques and highlight newer emerging treatments. Although treatment response is to some extent variable, there are a number of agents that are clearly useful as first-line treatments for TS. Other interventions may be of most benefit to patients exhibiting refractory tics or more specific symptom profiles.
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Affiliation(s)
- Clare M Eddy
- Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, UK
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Abstract
Tics are intermittent, repetitive, patterned but usually nonrhythmic motor movements or sounds performed in response to urges or involuntarily. They are the cardinal symptom required for a DSM-IV-TR diagnosis of Tourette's disorder (TD). Many children with TD present with mild tics that cause no significant impairment. However, when tics cause pain or interference, medical treatment is reasonable. This article reviews current evidence for treatment of tics in TD with medications as well as deep brain stimulation and transcranial magnetic stimulation. It concludes with some context for understanding this literature, relevant to treatment decisions and future treatment research in TD.
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Affiliation(s)
- Steve W Wu
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.
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Abstract
A tic is a stereotyped repetitive involuntary movement or sound, frequently preceded by premonitory sensations or urges. Most tic disorders are genetic or idiopathic in nature, possibly due to a developmental failure of inhibitory function within frontal-subcortical circuits modulating volitional movements. Currently available oral medications can reduce the severity of tics, but rarely eliminate them. Botulinum toxin injections can be effective if there are a few particularly disabling motor tics. Deep brain stimulation has been reported to be an effective treatment for the most severe cases, but remains unproven. A comprehensive evaluation accounting for secondary causes, psychosocial factors, and comorbid neuropsychiatric conditions is essential to successful treatment of tic disorders.
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Affiliation(s)
- David Shprecher
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY 14620, USA
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Abstract
Movement disorder emergencies include any movement disorder which evolves over hours to days, in which failure to appropriately diagnose and manage can result in patient morbidity or mortality. It is crucial that doctors recognize these emergencies with accuracy and speed by obtaining the proper history and by being familiar with the phenomenology of frequently encountered movements. These disorders will be discussed based on the most common associated involuntary movement, either parkinsonism, dystonia, chorea, tics or myoclonus, and, when available, review the workup and treatment options based on the current literature.
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Vincent DA. Botulinum toxin in the management of laryngeal tics. J Voice 2006; 22:251-6. [PMID: 17056228 DOI: 10.1016/j.jvoice.2006.08.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 08/24/2006] [Indexed: 11/28/2022]
Abstract
SUMMARY The objective of the study was to demonstrate the utility of botulinum toxin (BTX; Botox: Allergan Pharmaceuticals, Irvine, CA) type A injections for symptom reduction in laryngeal tics. The study consisted of case studies and literature review. Case histories of two patients with laryngeal tics are presented. Treatment was administered using BTX type A injected into the thyroarytenoid muscles using electromyographic guidance or via direct laryngoscopy. Treatment outcomes were measured using clinical rating scales with a range from 0 (no response) to 4 (maximal response). A subjective assessment of reduction in premonitory sensations was recorded. Subject 1 was a 49-year-old female with onset of laryngeal tic (throat clearing) at 46 years. She received six injections over 24 months. The lowest effective dose was 1.25 units bilaterally, producing complete resolution of the tic behavior (peak effect of 4/4) and reduction of the premonitory sensations. The median duration of benefit was 13 weeks. Subject 2 was a 14-year-old male with Gilles de la Tourette syndrome with laryngeal symptoms including throat clearing, barking, and crowing. He received three injections, with the lowest effective dose of 0.625 units bilaterally. He achieved marked reduction (peak effect of 3/4) of the throat clearing, barking, and crowing behaviors. There was also substantial reduction of the premonitory sensations. The median duration of benefit was 10 weeks. The cases presented herein are examples of successful treatment with low-dose BTX type A to reduce the symptoms of laryngeal tics, leading to improved quality of life. These cases add to the relatively small number of similar patients reported in the literature, and support the use of chemical neuromuscular blockade for treatment of laryngeal tic symptoms.
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Truong DD, Jost WH. Botulinum toxin: Clinical use. Parkinsonism Relat Disord 2006; 12:331-55. [PMID: 16870487 DOI: 10.1016/j.parkreldis.2006.06.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Revised: 06/21/2006] [Accepted: 06/21/2006] [Indexed: 01/25/2023]
Abstract
Since its development for the use of blepharospasm and strabismus more than 2.5 decades ago, botulinum neurotoxin (BoNT) has become a versatile drug in various fields of medicine. It is the standard of care in different disorders such as cervical dystonia, hemifacial spasm, focal spasticity, hyperhidrosis, ophthalmological and otolaryngeal disorders. It has also found widespread use in cosmetic applications. Many other indications are currently under investigation, including gastroenterologic and urologic indications, analgesic management and migraine. This paper is an extensive review of the spectrum of BoNT clinical applications.
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Affiliation(s)
- Daniel D Truong
- The Parkinson's and Movement Disorder Institute, 9940 Talbert Avenue, Fountain Valley, CA 92708, USA.
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Abstract
This article is structured around a literature review that was carried out using Ovid and Medline with the key words "botulinum," "toxin," and "ENT." Botulinum toxin has been used safely in humans for more than 20 years. The effects are transient, such that treatments are required to be repeated at intervals. Its application to ENT provides a useful tool to treat dystonia, autonomic dysfunction, facial nerve paresis, and hyperfunctional lines. It may also be of benefit in laryngeal rebalancing and the treatment of headaches. Further research is being carried out and new indications for treatment with botulinum toxin may include sialorrhea and rhinorrhea.
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Frucht SJ. Movement disorder emergencies. Curr Neurol Neurosci Rep 2005; 5:284-93. [PMID: 15987612 DOI: 10.1007/s11910-005-0073-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
For the past 4 years, Dr. Stanley Fahn and I have given a course at the American Academy of Neurology annual meeting on the topic of movement disorder emergencies. The purpose of this review article is to summarize the topic and to present it to readers of this journal. The text of this article has appeared in nearly the same form as the Academy syllabus accompanying our course. It is being presented here so that readers of the journal may review the material.
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Affiliation(s)
- Steven J Frucht
- Department of Neurology, Columbia University Medical Center, 710 West 168th Street, New York, NY 10032, USA.
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Abstract
Gilles de la Tourette's syndrome of chronic multiple motor and vocal tics is now acknowledged to be far more common than once thought, affecting up to 1% of schoolchildren with a wide range of severity. At the milder end of the spectrum the associated psychopathologies can in themselves impair social and educational functioning, in particular obsessive compulsive disorder and attention deficit hyperactivity disorder. Many patients with this condition are not being adequately served by health and education services in the UK. The epidemiology, clinical features, aetiological factors, and management of the syndrome are reviewed.
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Affiliation(s)
- J S Stern
- Tourette Syndrome (UK) Association, Atkinson Morley's Wing, St George's Hospital, Blackshaw Road, London SW17 0QT, UK.
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Abstract
This article reviews the evidence published in the English language literature concerning the pharmacological treatment of tics in patients with Tourette Syndrome. The focus is on the efficacy and safety of the current treatments. A clinical approach to pharmacological management of Tourette Syndrome patients is outlined.
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Affiliation(s)
- Paul Sandor
- Department of Psychiatry, Toronto Western Hospital, Edith-Cavell Wing, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8.
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28
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Abstract
Tourette's syndrome has been of neurologic and psychiatric interest since the original description of this condition by Gilles de la Tourette in 1885, and it has been associated with a wide variety of treatments over the years. With the advent of advances in neurochemistry and neuropharmacology, a neurobiologic approach has emerged with the application of many drugs from the fields of neurology and psychiatry. In addition, many of the comorbid conditions that coexist, such as attention deficit disorder and obsessive compulsive disorder (OCD), are amenable to both pharmacologic and behavioral approaches. Drug treatment has included dopamine receptor blockers for tics, dopamine agonists, dopamine depletors, and stimulants for attention deficit hyperactivity disorder (ADHD), noradrenergic drugs for tics and ADHD, serotonergic drugs for OCD, and chemical denervation for involuntary movements with the use of botulinum toxin and stereotactic surgery. It is the purpose of this review to outline the various approaches that are currently available as treatments, realizing that as new drugs are introduced in neurology and psychiatry, they too will find their way into treatment options.
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Affiliation(s)
- Bennett L Lavenstein
- Department of Neurology, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010, USA.
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Abstract
Correct education of the patient is one of the most important aspects in the treatment of Tourette's syndrome. Pharmacotherapy is often unsatisfactory and therefore should be limited to those patients who are significantly impaired. Therapy must be individualised and the most troublesome symptom should be targeted first. In the treatment of tics, dopamine receptor blocking agents are currently the most effective drugs. It is currently unknown whether classic neuroleptics, such as pimozide, selective dopamine receptor antagonists, such as sulpiride, or newer atypical antipsychotics, such as risperidone, have the best adverse effect profile. Tiapride can be used as an alternative, particularly in children. Selective serotonin-re-uptake inhibitors are recommended for the treatment of obsessive-compulsive behaviour. In children suffering from attention deficit hyperactivity disorder, psychostimulants, such as methylphenidate, are the treatment of choice. Recent studies have provided increasing evidence that stimulants do not cause a significant increase in tics in the majority of patients.
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Affiliation(s)
- Kirsten R Müller-Vahl
- Department of Clinical Psychiatry and Psychotherapy, Medical School Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
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Abstract
Tourette's disorder is a neuropsychiatric disorder characterised clinically by motor and vocal tics, which may be associated to conductual disorders such as obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD). Although the neurochemistry of Tourette's disorder is not well known, there are some effective therapies for tics, OCD and ADHD. However, these are not devoid of adverse effects. Tics only require treatment when they interfere with the functioning of the patient. If therapy is needed, monotherapy at the minimal effective dose is desirable, but some patients may require two or more drugs. The most frequently used drugs for tics are antipsychotics (mainly pimozide and haloperidol) and clonidine. The potential usefulness of atypical antipsychotic drugs (risperidone, olanzapine, clozapine, ziprasidone) and other dopaminergic drugs (fluphenazine, sulpiride, tiapride, metoclopramide, piquindone, tetrabenazine), clonazepam, calcium channel antagonists, botulinum toxin, dopamine agonists, selegiline, and other drugs is discussed. The drugs of choice for OCD in patients with Tourette's disorder are the selective serotonin reuptake inhibitors (SSRIs), although the tricyclic antidepressant clomiplamine, which inhibits both serotonin and noradrenaline uptake, has also been found to be useful. ADHD can be treated with some psychostimulants, mainly methylphenidate, although these drugs must be used with caution. Other potentially useful drugs for the treatment of ADHD in patients with Tourette's disorder are clonidine, guanfacine, selegiline, some tricyclic antidepressants, sertraline, pimozide and clonazepam. Finally, the potential value of some nonpharmacological therapies (hypnotherapy, biofeedback, conductual therapies, electroconvulsive therapy, acupuncture and surgery) is briefly reviewed.
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Affiliation(s)
- F J Jiménez-Jiménez
- Department of Medicine - Neurology, Hospital 'Príncipe de Asturias', Universidad de Alcalá, Alcalá de Henares (Madrid), and Neuro-Magister S.L. Company, Madrid, Spain.
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Affiliation(s)
- J Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
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Robertson MM, Stern JS. Gilles de la Tourette syndrome: symptomatic treatment based on evidence. Eur Child Adolesc Psychiatry 2001; 9 Suppl 1:I60-75. [PMID: 11140781 DOI: 10.1007/s007870070020] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The treatment of the Gilles de la Tourette syndrome has evolved from case reports, clinical experience and more recently blinded trials usually in small numbers of patients. We have reviewed the evidence available to clinicians. The oldest and still most widely prescribed drug, haloperidol, should now not be considered the first-line agent in children as other agents have superior adverse effects profiles. Symptomatic treatment should be targeted to the specific additional psychopathologies seen in the syndrome. For the treatment of tics, sulpiride, tiapride, possibly pimozide and in some cases clonidine may be considered first-line agents. Although a body of data supports pimozide, caution has to be exercised in relation to possible cardiac effects. Antidepressants and stimulants have an important place in the management of depression, obsessionality and attention deficit hyperactivity disorder. The latter also responds to clonidine making it a rational first choice where ADHD coexists with GTS. There are a multitude of other drugs advocated in the literature in addition to reports of neurosurgery and the novel use of immune modulation. Therapeutic trials for GTS are challenging. However, further data from blinded trials are required before many of these treatments can be considered to be mainstream treatment options.
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Affiliation(s)
- M M Robertson
- Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, University College, London, UK
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Abstract
Tics are the essential component of a variety of disorders, notably Tourette syndrome. Because the mere presence of tics does not require therapeutic intervention, criteria are essential for determining a functional disability. Suggested tic-suppressing treatments have been extremely diverse, including hydrotherapy, behavioral treatments, pharmacotherapy, botulinum toxin, immunomodulatory therapy, and surgery. This manuscript reviews each of these approaches with emphasis on more recent pharmacologic trials.
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Affiliation(s)
- H S Singer
- Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Harvey 811, Baltimore, MD 21287-8811, USA.
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Abstract
The role of botulinum toxin as a therapeutic agent is expanding rapidly in otolaryngology. Botulinum toxin is a protease that blocks the release of acetylcholine from nerve terminals. Its effects are transient and nondestructive, and largely limited to the area in which it is administered. These effects are also graded according to dose, allowing for individualized treatment of patients and disorders. Botulinum toxin has been used primarily to treat disorders of excessive or inappropriate muscle contraction. In the field of otolaryngology, these include spasmodic dysphonia, oromandibular dystonia, and blepharospasm; vocal tics and stuttering; cricopharyngeal achalasia; various tremors and tics; hemifacial spasm; temporomandibular joint disorders; and a number of cosmetic applications. Botulinum toxin treatment has recently begun to show some benefit in the control of pain from migraine and tension headache. It may also prove useful in the control of autonomic dysfunction, as in Frey syndrome, sialorrhea, and rhinorrhea. In over 20 years of use in humans, botulinum toxin has accumulated a considerable safety record, and in many cases represents relief for thousands of patients unaided by other therapy.
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Affiliation(s)
- A Blitzer
- New York Center for Voice and Swallowing Disorders, St. Luke's-Roosevelt Hospital Center, NY, USA
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Van Lancker D, Cummings JL. Expletives: neurolinguistic and neurobehavioral perspectives on swearing. BRAIN RESEARCH. BRAIN RESEARCH REVIEWS 1999; 31:83-104. [PMID: 10611497 DOI: 10.1016/s0165-0173(99)00060-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Severe aphasia, adult left hemispherectomy, Gilles de la Tourette syndrome (GTS), and other neurological disorders have in common an increased use of swearwords. There are shared linguistic features in common across these language behaviors, as well as important differences. We explore the nature of swearing in normal human communication, and then compare the clinical presentations of selectively preserved, impaired and augmented swearing. These neurolinguistic observations, considered along with related neuroanatomical and neurochemical information, provide the basis for considering the neurobiological foundation of various types of swearing behaviors.
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Affiliation(s)
- D Van Lancker
- Department of Neurology, University of Southern California, Los Angeles, CA, USA.
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Trimble MR, Whurr R, Brookes G, Robertson MM. Vocal tics in Gilles de la Tourette syndrome treated with botulinum toxin injections. Mov Disord 1998; 13:617-9. [PMID: 9613771 DOI: 10.1002/mds.870130348] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Abstract
Coprolalia has been a recognized symptom of Tourette syndrome from the first description of the syndrome. Copropraxia is seen less frequently and almost always occurs in association with coprolalia. Prevalence of coprolalia varies from 8% in primary pediatric practices to over 60% in tertiary referral centers. Coprolalia tends to peak in severity during adolescence and to wane during adulthood. The pathogenesis may be related to dysfunction of basal ganglionic and limbic mini-circuits. Coprolalia has also been seen in a variety of other neurologic disorders. Treatment is primarily pharmacologic with dopamine-blocking agents.
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Affiliation(s)
- C Singer
- Movement Disorders Clinic, Department of Neurology, University of Miami School of Medicine, Miami, Florida 33136, USA
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