New treatments for tic disorders.

Tics vary in severity from infrequent and barely noticeable to nearly continuous and highly disruptive. Treatment of tic disorders depends on the severity of the tics, the distress they cause, and the effects they have on school, work, or daily activities. Many tics do not interfere with school or everyday life and do not require specific treatment. Comorbid disorders such as attention deficit hyperactivity disorder, anxiety, and obsessive-compulsive disorder occur in more than 50% of patients. The associated comorbidity can be more bothersome than the tics themselves. Treatment should be aimed at the most troubling symptom. Education and reassurance are often sufficient for mild and occasional tics. For tics of moderate severity, clonidine and guanfacine have a reasonable safety profile. They are considered as first-line medications. With clonidine, start with 0.05 mg at bedtime. Increase as needed and as tolerated by 0.05 mg every 4 to 7 days to a maximum dosage of 0.3 to 0.4 mg/day divided three or four times a day. With guanfacine, start with 0.5 mg at bedtime. The dosage may be increased as needed and as tolerated by 0.5 mg every week to a maximum dosage of 3 to 4 mg/day, divided twice a day. There are emerging data that behavioral therapy is effective for treatment of tics in some individuals. Dopamine receptor blockers are the most potent medications for treating severe tics. The efficacy appears to be proportionate to the affinity for dopamine D2 receptors. Thus, standard antipsychotic medications such as haloperidol, pimozide, or fluphenazine are the most potent. However, these medications commonly cause bothersome side effects. Therefore, we recommend use of atypical neuroleptics before standard neuroleptics in most patients. Risperidone is usually the first choice and may have efficacy for behavior problems that often accompany tics. Start with 0.01 mg/kg/dose once a day; dosage may be increased by 0.02 mg/kg/day at weekly intervals, up to 0.06 mg/kg/dose once a day. Ziprasidone and olanzapine are reasonable alternatives.