European Child & Adolescent Psychiatry | 2021
Treating Tourette syndrome and other chronic tic disorders: updated guidelines by the European society for the study of Tourette syndrome (ESSTS)
Abstract
This edition of the European Child & Adolescent Psychiatry contains updated guidelines for the clinical management of adults and children with Tourette Syndrome (TS). TS and other chronic tic disorders together affect 1% or more of the European population, and may lead to emotional distress, physical pain, lower quality of life, and for many, functional impairment [1–4]. Tic disorders begin in early childhood, and for a substantial number of individuals, persist into adulthood. While TS is defined by the presence of motor and vocal tics, among those who present for clinical care, comorbid psychiatric disorders are the norm rather than the exception [5]. The two articles that cover pharmacological and behavioral management of TS, respectively, and are written by leading European experts and members of the European Society for the Study of Tourette Syndrome (ESSTS), manage to be rigorous and comprehensive, all while having the tone and feel of a one-to-one consultation between clinicians. The reviews assess the current prescribing practices of expert clinicians who routinely treat TS, and combine these with a review of the literature to arrive at treatment recommendations that are practical in nature and sensitive to current clinical settings and constraints. This work builds on and updates the parameters outlined in the TS Practice Guidelines published by the American Academy of Neurology (AAN) in 2019, which represents a synthesis of studies conducted prior to 2018 [6]. The ESSTS and AAN guidelines have substantial overlap in content and scope, and are largely consistent with one another. However, the ESSTS guidelines as presented here do differ from the AAN guidelines, in part because additional studies have been published in the time since the systematic review conducted by the authors of the AAN guidelines, in part, because of differing availabilities of and indications for pharmacological agents in the United States compared to Europe, but most importantly because of ESSTS’ clear focus on actual current clinician practice as a benchmark. For example, while both the AAN and the ESSTS guidelines discuss the need to assess for and treat cooccurring psychiatric comorbidities, more attention is paid to these comorbidities in the ESSTS guidelines, as well as to the off-target effects that pharmacological agents typically used to treat tics may have on other psychiatric symptoms. Pharmacological treatment of tics, while similar in scope and content, differs somewhat in order of choice between the two publications. For example, in the AAN guidelines, which focus on medications available and commonly used in the United States, alpha agonists such as clonidine and guanfacine are presented as the first line treatment for tics, while in the ESSTS guidelines published here, a second generation antipsychotic, aripiprazole, is the first line treatment. Similarly, while the AAN guidelines focus on Habit Reversal Therapy (HRT), and in particular on a specific form of HRT called Comprehensive Behavioral Intervention for Tics (CBIT), the ESSTS guidelines also discuss the evidence for and use of another form of behavioral therapy: exposure and response prevention (ERP) for the treatment of tics. This addition is of relevance not only because of additional data suggesting its efficacy, but also because providers in Europe and elsewhere are more likely to be familiar with the principles and practices of ERP than they are with those of HRT, as ERP is a gold standard treatment for obsessive compulsive disorder (OCD) and for anxiety disorders, which are highly prevalent disorders that frequently co-occur with TS. Thus, it is reasonable to assume that ERP may be readily modified for tics by clinicians who have experience with using it to treat OCD or an anxiety disorder. Experience This article is part of the focused issue “Update of the European clinical guidelines for Tourette Syndrome and other tic disorders”.