Treating Tourette's syndrome

There areseveral treatment options available for people with Tourette's syndrome.

The various treatments forTourette's syndromeare outlined below. You can also read a summary of the pros and cons of the treatments for Tourette's syndrome , allowing you to compare your treatment options.

Treatment plan

The first and most important part of treatment forTourette's syndromeis to ensure you, your child and, if needed, your childs teachers, friends and other family members all have good information and knowledge about the condition. This includes:

• being able to explain Tourettes syndrome to others if asked about tics
• understanding that tics are notput on
• understanding that tics come and go and sometimes they may be better than at other times
• knowing that having tics doesn't generally stop you doing anything you want to do
• knowing that treatments may help to relieve tics, but are unlikely to make them go away completely
• being aware that most people outgrow tics by the time they reach adulthood

Next, thetreatment planfor tics could involve one or more of the following:

• treatments that don't involve taking medication such as behavioural therapy
• medication the three types of medication that may be prescribed are alpha2-adrenergic agonists, muscle relaxants anddopamine antagonists
• surgery in extremely rare, severecases, surgical techniques may be suitable

Non-medical treatments alone, such asbehavioural therapy,may be needed if the Orthodontics are relatively mild and infrequent.

In cases where a person's tics are more severe and disrupt day-to-day activities, a combination of therapy and medication may be recommended.

Surgery is usually only recommended as a 'treatment of last resort' if the tics are particularly severe and fail to respond to other treatment.

The doctor in charge of your or your childs care, usually a neurologist (abrain and nervous system specialist), will recommend what they think is the best treatment option. However, the final decision will be yours.

If your child is old enough to understand fully the implications of their decision,they'll be asked to decide what treatment they prefer.

It's a type of psychological treatment designed to change the pattern of your or your childs behaviour.

Habit reversal

Habit reversal is a type of behavioural therapy that has proved successful in treating Tourettes syndrome. It's based on the following two principles:

• people with Tourettes syndrome are often unaware of their tics
• tics are used to relieve uncomfortable feelings, called premonitory sensations, that build up before tics

The first stage is to monitor the pattern and frequency of the tics, and identify any sensations that are triggering them. The next stage is to find an alternative, less noticeable method of relieving the premonitory sensations instead of a tic. This is known as a competing response.

For example, your child may experience an unpleasant sensation in their throat that causes them to grunt. Therefore, the next time your child feels the unpleasant sensation, they are asked to take a series of deep breaths rather than grunting, to try to relieve the sensation.

Habit reversal is often combined with relaxation therapy. Relaxation techniques , such as deep breathing or visualisation (thinking about something pleasant as a distraction), can help prevent feelings of stress and anxiety, which can often make tics worse.

Exposure and response prevention (ERP)

Exposure and response prevention (ERP) involves increasing exposure to the urge to tic in order to suppress the tic responsefor longer. This works on the theory that you get used to the feeling of needing to tic until the urge, and any related anxiety, decreases in strength.

Medication

Alpha2-adrenergic agonists

Alpha2-adrenergic agonists are usually recommendedfor treatment of mild to moderate symptoms of Tourettes syndrome.

This type of medication is thought to stabilise levels of a brain chemical called norepinephrine. This is thought to decrease the risk of the basal ganglia misfiring and triggering tics.

Clonidine is the alpha2-adrenergic agonist widely used to treat Tourettes syndrome.

Common side effects of clonidine include:

• drowsiness
• headaches
• dizziness
• fatigue
• constipation
diarrhoea a dry mouth
• difficulties sleeping

These side effects are usually mild and should improve when the body gets used to the medication.

Muscle relaxants

Muscle relaxants havebeen shown to be effective in helping control tics, particularly physical tics.

Baclofenandclonazepam are two muscle relaxants that are sometimes used to treat Tourettes syndrome. You or your child may feel drowsy and dizzy after taking these.

Adults being treated with muscle relaxants shouldn't drive or use tools or machinery if they feel dizzy or drowsy. You should also avoid drinking alcohol while taking muscle relaxants because it could make you feel very ill.

Dopamine antagonists

Dopamine antagonists are the most effective type of medication for preventing tics. However, they can cause a wide range of side effects, so will only be recommended in cases where the symptoms are particularly severe or fail to respond to other medications.

Dopamine antagonistsare given orally (as a tablet) or by injection. They work by blocking the effects of dopamine on the brain. Dopamine is a chemical in the brain thought to be associated with tics.

There are two main types of dopamine antagonists. They are:

• first generation dopamine antagonists developed in the 1950s
• a newer generation ofdopamine antagonists developed inthe 1990s

Both the older and newer dopamine antagonists have side effects, although not everyone experiences them, and their severity differs from person to person.

The side effects ofthe older dopamine antagonists include:

• drowsiness
• shaking
• trembling
• muscle twitches
• spasms

Side effects of both the older and newer dopamine antagonistsinclude:

• weight gain
• blurred vision
• constipation
• a dry mouth

The newer generation of dopamine antagonists are usually recommended because they're less likely to cause side effects. However, they aren't suitable or effective for everyone.

Adults with Tourettes syndrome who are being treated withdopamine antagonistsmay also experience a loss of libido (decreased sex drive).

If your child has been prescribed adopamine antagonist, and they're finding the side effects particularly troublesome, you should contact the doctor in charge of their care. There may be an alternative your child will be able to tolerate better.

Aripiprazole is the newest type of dopamine medicine thatseems to be helpful and appears to have fewer side effects. Although there hasn't yet been a large clinical trial of this medicine for Tourettes syndrome, it has been used successfully in many people with tics.

An experienced doctor may be able to offer aripiprazole as a treatmentoption.

Surgery and deep brain stimulation (DBS)

Surgery is usually regarded as a 'treatment of last resort' for people with severe Tourettes syndrome that has failed to respond to other treatments.It's usually only recommended for adults.

The aim of surgery is to make a small break in some of the pathways in the brain that may be responsible for tics. The region of the brain that is usually operated on is called the limbic system, although several different areas have been targeted.

Surgery has largely been replaced with deep brain stimulation (DBS). Thisis a relatively new technique that, like surgery, has been used to treat very severe cases of Tourettes syndrome where other treatments have failed.

DBS involves permanently implantingelectrodes (small metallic discs) in the parts of the brain known to be associated with Tourettes syndrome.

The electrodes are attached to small generators that are implanted elsewherein the body. The generators send electronic pulses to the electrodes, which stimulate different parts of the brain. By stimulating certain areas of the brain the symptoms of Tourettes syndrome can often be controlled.

Initial results of DBS have been encouraging, with some people showing a substantial reduction in their tics lasting for more than five years. DBS appears to be most effective when combined with behavioural therapy (seeabove).

However, both limbic system surgery and DBS haveonly beenused on asmall numberof people with Tourettes syndrome, and there's not yet sufficient evidence to justify their use as standard treatments for the syndrome.