9. Treatment of Tourette's Syndrome
The treatment of a patient suffering from Tourette's Syndrome will depend on the individual. Some people find that Tourette's Syndrome does not really interfere significantly with their everyday lives and hence do not need medication. In the treatment of a child, the primary emphasis must be to help the youngster through normal development. This is particularly aimed at the social and educational needs. i.e.. school, friendships and enable the child to experience normal childhood behaviours. Due to side effects, it is usually the patients with the severer tics that are prescribed medications. It is quite normal for a physician to follow a patients symptoms for several months and identify difficulties before prescribing any medications.
Keeping a patient informed about any disease which they are suffering from is always important. This is particularly important in Tourette's Syndrome due to the nature of the disease. An informed patient is much more able to make a good decision on whether or not to take medication. When children are affected, the parents should be kept up to date with new developments
Pharmacologic treatment remains the only proven effective treatment for tics due to Tourette's Syndrome. Patients are always started on the smallest dosage of medication possible. If no effects are seen, then the dosage is increased slowly. This allows a physician to assess the diminishment of symptoms and appearance of side effects. It is vital that the lowest effective dosage is used as many drugs carry long term side effects.
Useful Drugs used in the Prevention of Symptoms
Haloperidol (Haldol) has been the usual treatment for Tourette's Syndrome since the 1960's. It is available in solution form which can be beneficial if a patient (particularly children) dislikes taking tablets. It is widely accepted that Haloperidol is most effective at quite low doses, and patients are generally started on 0.25-0.50 mg/day and slowly increased (if necessary) to 3 or 4 mg/day for most patients. The treatment is very efficient in many cases. In some instances patients show complete remission and few side effects. Benefits are often observed from less than 1 mg/day. If low doses prove ineffective, higher doses (10-15mg/day) may give a reduction of symptoms. However side effects often limit the drugs usefulness.
The side effects of Haloperidol are fatigue, weight gain, memory problems, personality changes and sexual dysfunctions. Long term side effects are problematic and can often be confused with the symptoms of Tourette's Syndrome. For this reason some physicians seek the use of alternative drugs before Haloperidol.
Pimozide (Orap) is chemically distinctive from Haloperidol and is a potent Dopamine Blocker. Its side effects are similar to Haloperidol, but may be less severe and appear in fewer patients. In general, it is better tolerated than Haloperidol and is usually of equal efficacy.
Treatment with Pimozide is generally initiated at 1 mg/day, and dosage is gradually increased (only if needed), to a maximum of 6-10 mg/day for children and 20 mg/day for adults.
Fluphenazine, is an alternative to Haloperidol and Pimozide. Fluphenazine's side effects are mostly the same as those associated with Haloperidol, but some patients tolerate it better. The recommended dosage is similar to Haloperidol and the same principles apply to its administration. Other neuroleptics reported to be effective in a few patients include Thiothixene, Chlorpromazine, and Trifluoperazine.
Clonidine (Cataprese) is an alpha-adrenergic agonist. It has been considered to be of benefit in the treatment of Tourette's Syndrome although the response rate is lower than that of either Haloperidol or Pimozide. Its use is sometimes advantageous due to the low incidence of side effects.
In addition to reducing the simple motor and phonic symptoms in Tourette's Syndrome, Clonidine seems especially useful in improving attention difficulties and complex motor and phonic symptoms.
Dosage is started at low doses of 0.05 mg/day and slowly increased over several weeks to 0.15-0.30 mg/day. It is important that patients take small doses 3 to 4 times each day as it is rapidly removed from the body. An alternative to multiple doses is the transdermal patch that needs to be changed only once a week.
The major side effect of Clonidine is sedation. High doses, may cause hypotension and dizziness. If Clonidine is withdrawn from use on a patient, the dosage should be reduced gradually.
Psychotherapy will not eliminate tics, but it may prove beneficial in some instances. Tourette's Syndrome can cause a great deal of anxiety, anger, and particularly depression. Some patients appear withdrawn while others become aggressive. Self-esteem problems are common in Tourette's sufferers. Hence psychotherapeutic treatment may often benefit the patient.
Because Tourette's Syndrome is a genetic condition, families affected by the condition often seek clinical advise. Any such counseling must be provided by knowledgeable clinicians. Often a patient suffering from Tourette's Syndrome will want to know the chances of having a child affected by Tourette's Syndrome before deciding whether or not to start a family. This way the pro's and con's of such a major decision are easier to establish.