Pauline Anderson

June 07, 2017

VANCOUVER — Behavioral therapy is emerging as a first-line management of tic disorders, including Tourette syndrome.

In the last 5 to 10 years there has been a "paradigm shift" toward using what's called "habit reversal therapy," Jonathan W. Mink, MD, PhD, Frederick A Horner, MD, Endowed Professor in Pediatric Neurology and chief, Division of Child Neurology, University of Rochester Medical Center, New York, told Medscape Medical News.

Although he doesn't like the name of the therapy because tics don't involve a "habit," emerging evidence shows that the approach is as effective as pharmacotherapy, said Dr Mink.

He discussed this behavioral therapy approach and other tic treatments during a plenary session here at the International Congress of Parkinson's Disease and Movement Disorders (MDS) 2017.

Tics are often preceded by some kind of urge to carry out that tic. "The principle of habit reversal therapy is to identify that urge and to find a way to do what's called a 'competing response,' something that makes it impossible to do the tic," explained Dr Mink.

He used the example of a patient with a head-jerking tic. "When he feels the need to jerk his head, he contracts the muscles on both sides of his neck, making it impossible to jerk his neck because he's now stiffening his neck."

With practice, the response becomes automatic. The therapy works for any tic where "you can come up with a competing response," said Dr Mink.

Several studies, including a large National Institutes of Health–funded trial, have shown that this habit reversal approach is effective in both children and adults.

An increasing number of psychologists and occupational therapists are trained to administer the therapy, which generally involves an hour a week for 5 weeks with a subsequent booster session. But experts are developing a DVD-based self-instruction system for patients to use at home and working to make the therapy available through the Internet.

Evidence shows that the basal ganglia circuitry underlies chronic tics. "Movement learning" and "habit learning" occur in the basal ganglia, and because tics are learned, "you can learn to modify them," said Dr Mink.

This is a far cry from how tics used to be viewed. "People used to think that Tourette syndrome was some kind of defect in their will or character; it was some rebellion against parents, or some repressed sexual urge," said Dr Mink.

There has been "a lot of resistance" to the idea that behavioral therapy can change the brain, he said. "It took awhile for people to accept the idea because it was a move away from 'you can't control this; this is biological; take a medicine and you'll get better' to 'this is biological but you can actually control this if we teach you how to do it'," said Dr Mink.

Current guidelines in both Europe and Canada recommend this habit reversal approach as a first-line therapy. There are no formal guidelines in the United States, "but in the eyes of many people who specialize in Tourette syndrome here, this is a first-line therapy and is as effective as our first-line medicines," said Dr Mink.

The therapy has been tried in children as young as 6 or 7 years.

It could be said that habit reversal therapy is just replacing one tic with another one. However, "it doesn't matter, if that new one isn't bothersome," said Dr Mink.

Drug Options

In his presentation, Dr Mink discussed drug therapies for tics. These include α-2 adrenergic agonists, such as clonidine and guanfacine, and dopamine antagonists (antipsychotics).

"Probably the gold standard, the things that are the most effective, are the old-fashioned, potent, first-generation antipsychotics" such as haloperidol, Dr Mink told delegates.

He noted that he has used dopamine blockers to treat hundreds of children with Tourette syndrome and has never had a case of tardive dyskinesia.

Although many open-label studies have assessed tetrabenazine, a drug approved to treat chorea associated with Huntington's disease, there are no well-controlled trials with this drug for tics, said Dr Mink.

"Tics change with the season; tics change with different kinds of activities, and so unless you have a placebo group that is being followed over the same time, you run the risk of spurious results because of the timing and because there is a fairly strong placebo effect."

Benzodiazepines are another drug option to treat tics. "The only data really is for clonazepam, but all benzos are probably about the same in treating tics," said Dr Mink.

Although one controlled study found the anticonvulsant topiramate effective in treating tics, the dropout rate in that study was quite high, he said.

"Most of the treatments for tics are moderately effective in a moderate number of patients," concluded Dr Mink.

For drug therapy, the idea is to "start low, go slow and try to limit duration of treatment," he added.

Although deep-brain stimulation (DBS) has received a lot of attention for severe Tourette syndrome, the quality of the published data is generally not very good because the studies were unblinded or did not have validated outcome measures, said Dr Mink.

However, a 2015 randomized crossover trial of DBS in Tourette's did show significant improvement in tic severity, with an overall acceptable safety profile.

DBS "is something to consider for severe patients, but I don't know how consistent the effect will be," said Dr Mink.

Tics are common, Dr Mink told his audience. An estimated 20% to 25% of school-aged children will experience tics at some point and up to 3% will have chronic tics (occurring for more than a year). The mean age of tic onset is 5 to 7 years.

Tics often accompany other conditions, including anxiety, obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder. These other conditions are often more problematic than the tics themselves, said Dr Mink.

When deciding whether to treat tics, Dr Mink urged delegates to consider the patient's social interaction with peers, the impact on self esteem, and potential side effects of treatment. "If it is bothersome in any of those realms, treatment is probably a good idea, but that does not necessarily mean pharmacotherapy."

He stressed the importance of treating the tics that are the most bothersome to patients and to have a "realistic goal."

"We are not going to make these symptoms go away with any of our treatments, and so the goal is to make them tolerable."

The hypothesis that strep infection is linked to tics, known as the pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) theory, is "an interesting concept" but is "unsupported" by the evidence, said Dr Mink.

Cannabis Helpful?

Asked by a delegate whether cannabis helps control tics, Dr Mink said that although there are no controlled trials, in open-label studies patients have reported that their tics are better with cannabis.

"It may be effective because it has an anxiolytic property and when people are less anxious, their tics don't bother them as much as when they're feeling anxious."

He said he can "guarantee" that at least some patients with Tourette syndrome are "self-medicating" with cannabinoids.

Another delegate asked about a possible link between allergies and tic disorders.

Although he sees many kids who have both tics and allergies, "I'm not aware of any data that looked at whether there is any relationship," said Dr Mink.

Dr Mink has disclosed no relevant financial relationships.

International Congress of Parkinson's Disease and Movement Disorders (MDS) 2017. Therapeutic Plenary Session: Tic Disorders: Diagnosis and Treatment. Presented June 4, 2017.

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