Tourette Syndrome Plus - Conditions - Tics and Tourette's Syndrome

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Information Section: Conditions
Condition: Tourette's Syndrome
Article: Treatment of Tics and Tourette's Syndrome
Source: Leslie E. Packer, PhD
This File Last Updated: December 2004

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Botox Injections

In the past few years, there has been an increased interest in exploring the possible efficacy of botulinum toxin ("Botox"). Unlike central nervous system medications that affect the entire system, botulinum toxin acts locally (think of getting an injection of local anesthetic for dental work as an analogy for a locally acting medication). Awaad (1999) reported that in a series of 450 patients with TS, baclofen/botulinum toxin Type A was effective and safe, and subsequent studies have also indicated effectiveness in reducing tics, although global improvement outcomes vary between studies. For example, Marras et al. (2001) reported that botulinum toxin produced significant decreases in both tic frequency and urge to tic, but no patient-reported overall benefit from the treatment, whereas a more recent study by Porta et al. (2004) used botox injections for 30 patients with phonic tics associated with TS and reported not only rapid and significant tic reduction, but improved quality of life as reported by the participants. The one adverse effect noted was hypophonia (low speech volume or "quiet speech"), noted in 80% of the sample.

Marijuana

Although the use of marijuana may pose legal issues in many states and/or countries, it is worth noting that Mueller-Vahl (2003) provide pilot data demonstrating a significant reduction in tics in two studies: a single-dose crossover study with 12 adults and a randomized trial in 24 patients with TS. [U.S. patients who wish to find out more about the medical use of marijuana for tics or for other purposes may wish to see the web site of the National Organization for the Reform of Marijuana Laws, where you can find updates on research and links to your own state's laws.]

Habit Reversal Therapy

Habit reversal generally involves making the patient aware of the tic or the urge to tic building up and training the patient to engage in a response that would be muscularly competing or incompatible with the tic. Different investigators and clinicians may use slightly different variations in their protocols, but the competing response is a core feature of the technique.

The habit reversal technique has been discussed by Azrin and others [see Peterson & Azrin (1992) and Miltenberger et al. (1998 for discussions]. Habit reversal (HRT) is one of the only behavioral techniques for tics that has been empirically validated. For example, Wilhelm et al. (2003) recently compared HRT to supportive psychotherapy in a randomized groups design. The patients who received HRT showed significant decreases in tics compared to those who received supportive psychotherapy, and the improvement was maintained at the 10-month follow-up. Similarly, Woods, Twohig, et al. (2003) reported that 4 out of 5 children with vocal tics significantly reduced their vocal tics using HRT without any increase in untreated motor tics. The results of two other studies suggest that HRT produced an overall tic reduction of 30% with global improvement of 55%.

While more research on HRT is clearly needed, the recent studies are quite encouraging as they appear to provide a safe and effective means for tic reduction. When compared to medication for tics, HRT would probably take longer to achieve results than neuroleptic medications, but might take about the same amount of time as medications like clonidine. Unlike medications, however, HRT's effects might be limited or restricted to the targeted tic(s). That said, providing the patient with a tool or strategy to reduce distressing tics that they can use whenever they need to has distinct advantages if future studies replicate the findings of earlier studies.

The effectiveness of HRT can be augmented by adding in behavioral components that stem from conducting a functional behavioral assessment. As applied to tics, an FBA might suggest if there were any secondary gains for tics that might need to be addressed (e.g., escaping or avoiding homework, getting attention from parents).

Supplements, Vitamins, and the Like

Many patients and their families have inquired about the role of vitamins, minerals, supplements, and other regimens. There has been very little hard research on their efficacy in ameliorating the tics of Tourette's. If you're interested in anecdotal reports, you can find such discussions in online fora. Perhaps the most ardent proponents of alternative or complementary treatments is the organization known as Latitudes. Although much of their material has not been validated by the kinds of controlled research designs that are preferred, site visitors may find some helpful information or ideas that may work for themselves or family members. Of particular interest may be Sheila Roger's article, "Finding Triggers to Tics," Site visitors may also be interested in the hypotheses of Bonnie Grimaldi, who has developed a program for her son that she shares with others on the Bontech Supplements, Ltd. web site.

Deep Brain Stimulation

This past year has been a notable one as there has been much excitement about the use of deep brain stimulation (DBS) for treating severe intractable TS.

Note that stimulation is not the same as "lesioning," which would be the technique used in most surgical procedures that attempt to cut or sever pathways or structures. In DBS, the investigators are essentially providing an external source of stimulating one area of the brain to produce more activity. DBS involves placing the tip of a a very fine wire into the targeted area. The wire then runs up through a small hole in the skull and under the scalp down to a little device implanted under the collarbone. That device (a neurostimulator) sends tiny electrical impulses down the wire into the brain. The person can turn the DBS on when needed, and turn it off during sleep (when tremors are less). In some respects, DBS is like a pacemaker for the brain, but whereas a cardiac monitor adjusts the output automatically, with DBS, the individual can adjust the output from the stimulator.

Visser-Vandewalle et al. (2004) presented three cases of bilateral thalamic stimulation and reported that at long-term follow-up, all major tics had disappeared as well as associated behavioral disturbances. At about the same time, another report appeared from a neurosurgical team at University Hospitals of Cleveland. These investigators reported that the patient -- who had suffered from Tourette's since age 6 -- had an immediate and nearly complete cessation of symptoms.

Such studies provide some promise and hope for those with severe and treatment-resistant Tourette's, but require long-term study and larger samples before any meaningful conclusions can be drawn about the effectiveness of this approach.

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