In general, we recommend psychotherapy if available (see below) rather than pharmacotherapy as the first-line treatment for Tic Disorders. Where there is insufficient clinical response to an appropriate course of psychotherapy, or where symptoms are severely disabling, antipsychotic medication can be considered, after careful evaluation and discussion with the patient of the positive and negatives associated with particular antipsychotic medication treatment. The threshold for prescribing antipsychotics is lower in adults due to more safety data being available, and knowledge that adult Tic Disorders are more functionally impairing and persistent than the childhood onset form.
In the special case of moderate to severe Tic Disorder plus ADHD, we recommend an alpha-2 receptor agonist (clonidine or guanfacine) as a first-line option for children and adults, in addition to psychotherapy.
Baseline investigations prior to initiation of antipsychotic medication should include an EKG (ECG), fasting lipid levels and glucose, liver function tests, urea and electrolytes, full blood count, and prolactin; pulse and blood pressure should be recorded along with body mass index and waist circumference. These should be repeated at 6 months, then at 1 year, then annually thereafter (unless there are specific concerns).
Before starting an alpha-2 receptor agonist, an EKG (ECG) should be undertaken; blood pressure and pulse should also be recorded. Following any dose increases, it is prudent to repeat these investigations.
Before starting psychotherapy, the clinician should make sure the patient (and family, in the case of children) knows the intended number of therapy sessions, and the need to perform homework assignments.