Tourette Syndrome: When Tics Change, Should Care Change?

Tourette syndrome (TS) presents a complex clinical challenge because clinicians must distinguish typical neurodevelopmental tics from functional tic-like behaviors (FTLBs) while also addressing frequent psychiatric and neurodevelopmental comorbidities. The marked increase in FTLBs reported during the COVID pandemic has further complicated diagnosis. At the same time, advances in behavioral and pharmacologic treatments have expanded options for patients with persistent or severe tics.TS was described in the late 19th century by Georges Gilles de la Tourette.TS is characterized by multiple motor tics and at least one vocal tic that persist for more than 1 year and begin before age 18. The condition typically begins in childhood and follows a fluctuating course. Symptoms often improve by the end of adolescence, although tics persist into adulthood in about one third of patients.Motor and vocal tics can be simple, including repetitive movements, sniffing, or throat clearing, or complex, involving coordinated movements or the utterance of words or phrases. Coprolalia, the involuntary utterance of obscene words or expressions, is often considered a characteristic feature of TS but occurs in only about 20% of patients.Tics are often preceded by unpleasant premonitory sensations that are temporarily relieved by performing the tic. Symptoms may become more pronounced during periods of stress, fatigue, or excitement and may decrease during activities that require sustained attention.Psychiatric and neurodevelopmental comorbidities are common. These include attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety disorders, learning disabilities, and autism spectrum disorder.Diagnosis, Mechanisms, and TreatmentUnderstanding of TS has advanced in recent years. Large-scale genome-wide association studies have mapped extensive genetic overlaps, revealed a hereditary component, and identified genetic factors shared with ADHD, OCD, and autism spectrum disorder.From a pathophysiologic perspective, TS is considered a neurodevelopmental disorder involving impaired inhibitory mechanisms within brain circuits responsible for motor control.TS is diagnosed clinically on the basis of the patient’s history and examination. Additional testing is generally unnecessary when the clinical presentation is typical, and no atypical features are present.Diagnosis can become more challenging when symptoms resemble FTLBs. Specialists have reported an increase in these behaviors since the COVID pandemic.Unlike classic TS, which typically begins in childhood and is more common in boys, FTLBs occur predominantly in adolescent girls and young women. Anxiety, depression, and adverse psychosocial events shortly before symptom onset are also more common in this group.Exposure to certain types of tic-related content on social media has been identified as a potential contributing factor, although this association does not establish a causal relationship.Personalized CareManagement of TS can be complex, particularly in patients with severe symptoms, and may require coordinated care involving neurologists, psychiatrists, psychologists, and other healthcare professionals.For patients with mild symptoms, education for the patient and family social support, and psychological support may be sufficient.Drug therapy may be considered for moderate-to-severe symptoms, with antipsychotics among the main pharmacologic options. Aripiprazole is commonly used because of its more favorable tolerability profile than that of older antipsychotics, although it has not received marketing authorization for this indication in France.Cognitive-behavioral therapy is an established nonpharmacologic treatment for tics. The best-validated approach is cognitive-behavioral intervention for tics, which teaches patients competing responses to reduce tic expression and incorporates relaxation techniques, self-monitoring, and behavioral reinforcement.Botulinum toxin injections may be considered for selected localized tics, whereas deep brain stimulation may be an option for patients with the most severe and treatment-refractory symptoms.When symptoms substantially affect daily functioning, the French National Authority for Health recommends specialized evaluation of tic severity and potential comorbidities. The primary care physician can coordinate ongoing care across specialties.New pharmacologic approaches are also being investigated. Ecopipam, a selective dopamine D1 receptor antagonist, is among the treatments attracting interest.In an international phase 3 trial involving 216 patients, ecopipam reduced the risk for relapse by 53% compared with placebo in children and adolescents with TS (hazard ratio, 0.47; 95% CI, 0.26-0.84). The treatment maintained a clinically significant improvement in symptoms for up to 24 weeks.Ecopipam had a favorable safety profile, with no treatment-induced movement disorders reported. The most common adverse effects were drowsiness, anxiety, headache, insomnia, and fatigue.This story was translated from Univadis France, part of the Medscape Professional Network.