In a minority of cases, individuals with tics may present due to friends or relatives being concerned, rather than any distress from the affected individual; in such cases, treatment may not be needed. In the case of new, subtle, or non-distressing tics, it may be appropriate to take a “watchful waiting” approach, with outpatient follow-up, and consideration of treatment at a later date.
Before rushing in with specific treatment for the Tic Disorder itself, consider whether co-morbid disorders are present, and treat these as a priority. This is particularly important for co-morbid OCD and ADHD, where treatment of these symptoms may have beneficial effects on tics, too.
Antipsychotic medications are regarded as the most effective established pharmacological treatment for tics, although their side effect profiles are problematic and hinder their clinical use. The antipsychotic medications studied most for the treatment of Tic Disorders are: risperidone, pimozide, and haloperidol. Aripiprazole has also been explored but further controlled trials are needed.
The alpha-2 receptor agonist medications clonidine and guan- facine also show efficacy in the treatment of tics, and were traditionally recommended over-and-above antipsychotics, due to their superior side effect profiles. However, recent meta-analysis suggests that alpha-2 receptor agonists are only of significant clinical benefit when used in patients with Tic Disorder plus ADHD, rather than Tic Disorder alone.
Adult dosing guidelines are as follows (for doses in children/ado- lescents see the relevant section elsewhere in this book):
- • Risperidone: Start with 0.5 or 1mg per day, and increase at intervals of 2-7 days in steps of 0.5-1mg per day, depending on progress. The mean effective dose is 3mg. Suggested maximum 6mg per day. Can be given once daily or in two divided doses.
- • Pimozide: Start with 1mg per day, and increase at intervals of 1mg per day every 2-7 days, depending on progress. The mean effective dose is 3mg per day. Suggested maximum 6mg per day.
- • Haloperidol: Start with 0.5mg per day, and increase at intervals of 2-7 days in steps of 0.5mg per day, depending on symptom response and tolerability. Suggested maximum dose is 3mg per day.
- • Clonidine: Start with 50 micrograms twice each day, increasing after two weeks to 75 micrograms twice each day (if needed) and if physical observations are acceptable (blood pressure and pulse).
- • Guanfacine: Start with 1mg per day, and increase at intervals of one week by 0.5-1mg per day, depending on response, and if physical observations are acceptable (blood pressure and pulse). Recommended maximum 4mg/day.