Canadian Guidelines for the Evidence-Based Treatment of Tic Disorders

Abstract

Canadian treatment guidelines regarding the management of tic disorders, including Tourette syndrome (TS), have have been long overdue. Ever since the syndrome was first described by Georges Gilles de la Tourette in 1885,' TS was considered to be a rare but fascinating disorder. There are now considerable data that document the prevalence of TS to be around 1% of the general population.2 This means that the average general practitioner with a caseload of 3000 patients will care for about 30 patients with this condition. The many different agents that have been in use reflects that no ideal treatment has emerged, to date. Moreover, there has been no clear consensus in Canada about the sequence in which the available treatments should be employed. Treatment becomes more complex yet when one considers that more than one-half of patients with TS present with concurrent disorders, such as attention-deficit hyperactivity disorder and (or) obsessive-compulsive disorder.3 Therefore, it is important to provide an up-to-date overview of the evidence regarding treatments currently in use, as well as guidelines based on the best available evidence. Although clinical guidelines for the treatment of TS have been recently published in other jurisdictions,46 there are variations in the availability of interventions and in clinical practices to justify the need for clinical guidelines that reflect the Canadian context. TS begins in childhood and can have a negative effect on the child's functioning as well as psychological wellbeing.7·8 Without timely intervention, this can often lead to detrimental long-term effects on social adaptation, academic success, self-image, and self-esteem. These risks are particularly important for children who have not only TS but also one or more comorbid conditions. In general, one can intervene at 3 levels: educational, psychotherapeutic, and pharmacological. It is important to emphasize that a person and their family can benefit from receiving the diagnosis and learning about the nature of the condition, including its natural course and prognosis. In most mild cases, that is sufficient to allow them to cope with the symptoms successfully. However, the clinician must be sensitive to the great variability in the tolerance of tics among affected people and families. Consequently, the decision of whether and when to move on to more active interventions, such as behavioural treatment or pharmacotherapy, depends, to a considerable extent, on the attitude and needs of patients and their families, which have to be evaluated patient by patient. It is for that reason that one cannot specify a particular frequency or severity of tics as a threshold beyond which treatment is always necessary. Instead, the treatment should be offered when the symptoms interfere with academic, vocational, or social functioning, or cause physical pain or psychological distress. Moreover, it is important to keep in mind, and to educate patients, that for most people with TS, the tics subside on their own by the end of adolescence.' Awareness of this typical natural course of tics often leads to a more conservative approach to treatment, especially when considering medications that are associated with significant adverse effects. Further, highly invasive experimental treatments, such as psychosurgery, should be avoided in patients aged 20 years and younger. Frequently, tics are less pronounced at school than at home because of the tendency to inhibit them in public, albeit at the cost of reduced attention and increased irritability. Nevertheless, tics are often experienced as disruptive and embarrassing in the school setting. There is room here for professional intervention in terms of recommending practical strategies, which often include informing teachers and classmates about the nature of tics to avoid unwarranted reprimands and teasing. Advising patients on how to handle questions about their tics is also useful and important. …