Considerations of natural history and pathophysiology in the psychopharmacology of Tourette's syndrome.

BACKGROUND: The increasing recognition of Tourette's syndrome is probably responsible for the broadening range of symptom severities seen in clinic patients. Greater clinical diversity also brings greater treatment challenges, particularly for children in whom the risks and benefits of medication for the developing central nervous system must be weighed against the long-term risks associated with the disorder itself. Knowledge of the natural history and pathophysiology of Tourette's syndrome is vitally important for informed clinical decision making.
METHOD: A MEDLINE literature search was undertaken to identify studies of the natural history and pathophysiology of Tourette's syndrome that would be relevant to clinical psychopharmacology.
RESULTS: Although impossible to predict with certainty for any given patient, the natural history of Tourette's syndrome is typically characterized by an early childhood onset, a prepubertal exacerbation, postpubertal attenuation, and an adult stabilization of symptoms. Symptoms fluctuate in all phases of the illness, often in response to stress. The natural history and clinical phenotype of Tourette's syndrome are thought to have both genetic and nongenetic determinants that are mediated through their effects on basal ganglia nuclei and related neural systems. Medications used in the treatment of Tourette's syndrome are thought to modulate the functioning of these neural systems.
CONCLUSION: Although medication decisions must consider tic symptom severity, expectations of the disorder's natural history, and the child's adaptive capacities-his or her comorbid illnesses, coping mechanisms, interpersonal relatedness, impulse control, affect regulation, and family and social supports-are the most important determinants of well-being and outcome. These therefore are the most important considerations when making treatment decisions, as well.