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

	Site Map	Conditions	Education
	Behavior	Miscellaneous	Home

Information Section: Conditions
Condition: Tourette's Syndrome
Article: Treatment of Tics and Tourette's Syndrome
Source: Leslie E. Packer, PhD
This File Last Updated: February 2009

Article Page 1 2

Botox Injections

Some investigators have explored the possible efficacy of botulinum toxin ("Botox") in decreasing tics. 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 subsequent 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. Despite what appears to be its promise in treating vocal tics, there has been very little controlled research published on this approach in the past few years.

Marijuana

Although the use of marijuana may pose legal issues in many states and/or countries, it is worth noting that Mueller-Vahl (2003) provided 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. Unfortunately, they do not seem to have published any controlled studies since that time and we have no subsequent research on this topic. [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.]

Behavior Therapy: Habit Reversal Therapy (Cognitive Behavior Intervention Tics) and Exposure-Response Prevention

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. In recent years, the name "Habit Reversal Therapy" was changed to "Cognitive Behavior Intervention for Tics" (CBIT) because it was feared that the word "Habit" was incorrectly suggesting that tics were voluntarily learned behaviors.

CBIT is one of the only behavioral techniques for tics that has been empirically validated. For example, Wilhelm et al. (2003) compared HRT (now CBIT) 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 a number of studies suggest that CBIT reduces tics, although not necessarily in all subjects, and it does not eliminate all tics (cf, Himle & Woods, 2008) (pdf).

Ongoing research by Dr. Douglas Woods and his colleagues continues to shed light on the effectiveness of CBIT. In some of his more recent studies, the investigators demonstrated that active suppression of tics for reinforcement did not lead to any later "rebound" in tic frequency or severity. Although much more research is needed, it is clear that the approach may be of benefit to some and parents of children 10 or older who do not want to consider medications may wish to learn more about the techique.

Another behavioral approach that shows promise is Exposure- Response Prevention, although it has not accummulated as much research. In ERP, the patient feels the urge to tic building, but does not allow the tic to be expressed. Verdellen and her colleagues report that not only do tics decrease during and between sessions, but the urge to tic habituates and decreases. ERP is the same approach that has been very successful in treating Obsessive-Compulsive Disorder, and it will be interesting to see what future research suggests.

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.

In Spain, Dr. López-Garcia and colleagues conducted an open label study of magnesium and vitamin B6. Children and teen's TS symptoms were measured periodicially over a period of three months. They reported significant reductions in symptoms as measured by the Yale Global Tics Severity Scale. Again, without any randomized controls, it is difficult to draw any firm conclusions because if my Spanish hasn't totally failed me, it seems like they started administering the magnesium and B6 during a cycle of symptom worsening. If that's the case, then symptoms would have likely declined anyway due to the nature of waxing and waning cycles. The biggest decreases seem to have occurred two weeks after initiation, with continuing smaller decreases noted thereafter.The study is reportedly ongoing, and Dr. Garcia-Lopez informs me that they have no definitive results regarding its efficacy yet (personal communication, 2009). I look forward to reading a full report in English.

Deep Brain Stimulation

When conservative treatment fails in patients with severe TS, deep brain stimulation (DBS) may be a therapeutic option. DBS involves placing the tip of a a very fine wire into the targeted area of the brain. 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.

Welter et al. (2008) conducted a controlled, double-blind, randomized crossover study. They found a dramatic improvement on the Yale Global Tic Severity Scale with bilateral stimulation in part of the basal ganglia. Ackermans et al. (2008) provide a review of recent research on DBS.

Article Page 1 2

	Site Map	Conditions	Education
	Behavior	Miscellaneous	Home