Clinical Pharmacology of Comorbid Obsessive–Compulsive Disorder in Tourette Syndrome

Current and emerging pharmacotherapeutic strategies for Tourette syndrome

INTRODUCTION

Tourette syndrome (TS) is a chronic tic disorder characterized by both motor and vocal tics. The vast majority of patients present with co-morbid behavioral problems, especially tic-related obsessive-compulsive behaviors and attention-deficit and hyperactivity disorder. Evidence-based guidelines on the pharmacotherapy of TS have become available in recent years.

AREAS COVERED

The main purpose of this paper is to provide an overview of the current and emerging pharmacotherapeutic strategies for TS. A comprehensive search for the literature on the pharmacotherapy of tics was conducted using multiple databases (MEDLINE, Scopus, Web of Science, and Google Scholar), without date limits.

EXPERT OPINION

In consideration of the heterogeneity of the TS phenotypes, pharmacotherapy should be tailored to the individual patient. The choice of the pharmacological agent should take into account both the efficacy-to-tolerability ratio and the presence of co-morbid conditions. Evidence-based pharmacotherapy should aim at improving health-related quality life within a dynamic framework that typically requires active monitoring of the clinical presentation and reevaluation of the treatment intervention over time.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part III: pharmacological treatment

In 2011, the European Society for the Study of Tourette Syndrome (ESSTS) published the first European guidelines for Tourette Syndrome (TS). We now present an update of the part on pharmacological treatment, based on a review of new literature with special attention to other evidence-based guidelines, meta-analyses, and randomized double-blinded studies. Moreover, our revision took into consideration results of a recent survey on treatment preferences conducted among ESSTS experts. The first preference should be given to psychoeducation and to behavioral approaches, as it strengthens the patients' self-regulatory control and thus his/her autonomy. Because behavioral approaches are not effective, available, or feasible in all patients, in a substantial number of patients pharmacological treatment is indicated, alone or in combination with behavioral therapy. The largest amount of evidence supports the use of dopamine blocking agents, preferably aripiprazole because of a more favorable profile of adverse events than first- and second-generation antipsychotics. Other agents that can be considered include tiapride, risperidone, and especially in case of co-existing attention deficit hyperactivity disorder (ADHD), clonidine and guanfacine. This view is supported by the results of our survey on medication preference among members of ESSTS, in which aripiprazole was indicated as the drug of first choice both in children and adults. In treatment resistant cases, treatment with agents with either a limited evidence base or risk of extrapyramidal adverse effects might be considered, including pimozide, haloperidol, topiramate, cannabis-based agents, and botulinum toxin injections. Overall, treatment of TS should be individualized, and decisions based on the patient's needs and preferences, presence of co-existing conditions, latest scientific findings as well as on the physician's preferences, experience, and local regulatory requirements.

Psychopharmacotherapy of Obsessive-Compulsive Symptoms within the Framework of Tourette Syndrome

While Behavioral Therapy (BT) should be recommended as the first step in the treatment of OCD as well as TS, medication can be added for augmentation and in certain situations (e.g. family preference, BT not available or feasible) the priority may even reverse. This narrative review is given on the complexity of drug treatment in patients comorbid with obsessive-compulsive disorder (OCD) and Tourette syndrome (TS) and other tic problems. OCD with TS is a co-occurring combination of the two generally delimitable, but in detail, also overlapping disorders which wax and wane with time but have different courses as well as necessities and options of treatment. Distinct subtypes like “tic-related OCD” are questionable. Obsessive-compulsive symptoms (OCS) and tics are frequently associated (OCS in TS up to 90%, tics in OCD up to 37%). Sensory-motor phenomena like urges and just-right feelings reflect some behavioral overlap. The main additional psychopathologies are attention-deficit hyperactivity disorder (ADHD), mood problems and anxiety. Also, hair pulling disorder and skin picking disorder are related to OCD with TS. Hence, the assessment and drug treatment of its many psychopathological problems need high clinical experience, careful planning, and ongoing evaluation/adaptation. Drugs are able to reduce clinical symptoms but cannot cure the disorders, which should be treated in parallel in their own right; i.e. for OCD serotonin reuptake inhibitors (SSRI) and for TS (tics), certain antipsychotics can be successfully prescribed. In cases of OCD with tics, when OCS responds only partially, an augmentation with antipsychotics (recommended: risperidone and aripiprazole) may improve OCS as well as tics. Also, the benzamide sulpiride, an atypical antipsychotics, may be beneficial in treating the combination of OCS, tics and anxious-depressive problems.

Probably, any additional psychopathologies of OCD might attenuate the effectiveness of SSRI on OCS; on the other hand, in cases of OCD with tics, SSRI may reduce not only OCS but also stress sensitivity and emotional problems and thus leading to better selfregulatory abilities, useful to improve tic suppression.

In sum, some clinical guidance can be given, but there remain many uncertainties because of a scarce database for psychopharmacotherapy in OCD with TS.

Treatment-refractory Tourette Syndrome

Tourette Syndrome (TS) is a complex neurodevelopmental condition marked by tics and frequently associated with psychiatric comorbidities. While most cases are mild and improve with age, some are treatment-refractory. Here, we review strategies for the management of this population. We begin by examining the diagnosis of TS and routine management strategies. We then consider emerging treatments for refractory cases, including deep brain stimulation (DBS), electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and novel pharmacological approaches such as new vesicular monoamine transporter type 2 inhibitors, cannabinoids, and anti-glutamatergic drugs.

Pharmacotherapy for obsessive compulsive disorder in clinical practice - Data of 842 inpatients from the International AMSP Project between 1994 and 2012

BACKGROUND

Specific treatment of obsessive compulsive disorder (OCD) is based on cognitive-behavioral therapy, serotonin reuptake inhibitors (SRIs) or their combination. Treatment strategies do not always follow evidence-based guidelines in outpatient settings. Data on pharmacotherapy in inpatient settings are lacking.

METHODS

Prescription data for inpatients suffering from OCD in the time period 1994-2012 were obtained from the database of the Drug Safety Program in Psychiatry (AMSP). Data were collected on two index dates per year; the prescription patterns and changes over time were analysed.

RESULTS

Of 842 patients 89.9% received at least one psychotropic drug and 67.6% a combination of at least two psychotropic drugs. The drug groups prescribed most often were antidepressants (78.0%), antipsychotics (46.7%), and tranquilizers (19.7%). In 58.0% of all cases selective serotonin reuptake inhibitors (SSRIs) were used as antidepressants, followed by tricyclic antidepressants (TCAs, 17.8%), mainly clomipramine (10.9%). Second-generation antipsychotics (SGAs) were administered in 37.8% of all cases, first-generation antipsychotics (FGAs) in 13.7%. While the use over time significantly increased for psychotropic drugs, antidepressants, antipsychotics, tranquilizers, SSRIs and SGAs, it remained stable for FGAs and decreased for TCAs.

LIMITATIONS

Observational cross-sectional study without follow-up or additional information.

CONCLUSIONS

In clinical practice, most OCD patients received pharmacological treatment. The high prescription rate of SSRIs and their preference over clomipramine as well as the augmentation of this therapy with SGAs comply with the guidelines. Administration of tranquilizers as well as sedative FGAs and the choice of single SGAs are not in line with expert recommendations.

A selective review of glutamate pharmacological therapy in obsessive-compulsive and related disorders

Glutamate, an excitatory central nervous system neurotransmitter, is emerging as a potential alternative pharmacological treatment when compared to gamma-aminobutyric acid (GABA)-, dopamine-, and serotonin-modulating treatments for neuropsychiatric conditions. The pathophysiology, animal models, and clinical trials of glutamate modulation are explored in disorders with underlying inhibitory deficits (cognitive, motor, behavioral) including obsessive–compulsive disorder, attention deficit hyperactivity disorder, Tourette syndrome, trichotillomania, excoriation disorder, and nail biting. Obsessive–compulsive disorder, attention deficit hyperactivity disorder, and grooming disorders (trichotillomania and excoriation disorder) have emerging positive data, although only scarce controlled trials are available. The evidence is less supportive for the use of glutamate modulators in Tourette syndrome. Glutamate-modulating agents show promise in the treatment of disorders of inhibition.