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05. Tic Disorders and Psychiatric Comorbidities

Published on April 1, 2023 Certification expiration date: April 1, 2026

David R. Rosenberg, M.D.

Chair of the Department of Psychiatry & Behavioral Neuroscience - Wayne State University School of Medicine

Key Points

Decreased response rates to SSRIs have been observed in children with tic-related OCD.
CBT is considered the first-line treatment for tic-related OCD.
Depression is associated with earlier onset, greater severity, and longer duration of tics.
Irritability, mood instability, and emotional dysregulation are common in youth with tic disorders.

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Slides and Transcript

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Video 5, tic disorders and psychiatric comorbidities.

Tic Disorders and Psychiatric Comorbidities Slide 1 of 25

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Other psychiatric conditions are frequently associated with tic disorders. Between 80% to 90% of patients with tic disorders have one or more comorbid psychiatric disorders.

References:

Ueda, K., & Black, K. J. (2021). A comprehensive review of tic disorders in children. Journal of Clinical Medicine, 10(11), 2479.

Tic Disorders and Psychiatric Comorbidities Slide 2 of 25

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The most common psychiatric comorbidities include ADHD and obsessive-compulsive disorder as well as anxiety and mood disorders and disruptive and self-injurious behavior.

References:

Ueda, K., & Black, K. J. (2021). A comprehensive review of tic disorders in children. Journal of Clinical Medicine, 10(11), 2479.

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In many patients, treatment of comorbid psychiatric conditions may actually take precedence over tic symptoms as the functional impairment caused by comorbid disorders may have a more significant clinical impact on the overall quality of life.

References:

Ueda, K., & Black, K. J. (2021). A comprehensive review of tic disorders in children. Journal of Clinical Medicine, 10(11), 2479.

Tic Disorders and Psychiatric Comorbidities Slide 4 of 25

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Tic disorders and ADHD. This is a very common comorbidity and it’s especially noteworthy that it can be more strongly associated with functional impairment. Severe tics can interfere with attention and concentration while anxiety related to tics and premonitory urges can be very distracting and may also present as fidgetiness commonly seen in ADHD.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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Comorbid ADHD is likely to attenuate overall decreases in tic symptom severity. That being said, behavior therapy is still very beneficial for youth with ADHD and tics and it’s something we’ll discuss in more detail soon.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

Tic Disorders and Psychiatric Comorbidities Slide 6 of 25

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The alpha-2 agonists, clonidine and guanfacine, are recommended as first-line pharmacological treatment for combined ADHD and tics. Guanfacine is generally preferred since it causes less sedation than clonidine and it’s not associated with rebound hypertension following medication withdrawal as clonidine is.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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That being said, as we’ve discussed before, the stimulant medications are so powerfully effective in ADHD, overall have such a benign side effect profile for most patients, and more recent data suggest that this does not aggravate tics and may help both tics and ADHD behaviors. So this is an important area to consider, that the alpha-2 agonists can be very much indicated in this population but don’t rule out the stimulants.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

Tic Disorders and Psychiatric Comorbidities Slide 8 of 25

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And sometimes, the combination of an alpha-2 agonist with a stimulant can be highly effective for treating comorbid ADHD in tics.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

Tic Disorders and Psychiatric Comorbidities Slide 9 of 25

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Atomoxetine is another effective nonstimulant that has been identified as a useful treatment to reduce ADHD symptoms without worsening tic symptoms. However, this medication does not appear to have any anti-tic effects, that is it’s not going to decrease tics but it doesn’t appear to increase tic symptoms.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

Tic Disorders and Psychiatric Comorbidities Slide 10 of 25

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Tic disorders and obsessive-compulsive disorder. This is referred to as tic-related obsessive-compulsive disorder and has important prognostic significance since there is a decreased response rate to SSRIs which has been noted in youth with OCD and comorbid tic disorders. So children and adolescents who have OCD alone have a much better response to SSRIs alone than do patients with comorbid tics.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). Introduction to treatment and management of youth with tourette disorders and tic disorders. The Clinician's Guide to Treatment and Management of Youth With Tourette Syndrome and Tic Disorders, 1-20.

Tic Disorders and Psychiatric Comorbidities Slide 11 of 25

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The CBT (cognitive behavioral therapy) is considered first-line treatment of OCD in individuals with tic disorders.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

Tic Disorders and Psychiatric Comorbidities Slide 12 of 25

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Exposure and response prevention is another effective intervention for treating pediatric OCD and which has some preliminary evidence to support its use for tic disorders as well.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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For children with OCD and tic disorder or where it’s difficult to distinguish between tics and compulsions, ERP or a combination of exposure and response prevention plus habit reversal therapy may target the greatest number of symptoms.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

Tic Disorders and Psychiatric Comorbidities Slide 14 of 25

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And given the poor response to SSRIs, clinicians may need to consider clomipramine augmentation for obsessive-compulsive disorder treatment. Clomipramine has demonstrated superior efficacy for OCD symptoms over SSRIs but it is associated with a much less favorable adverse effect profile.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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And there are also exciting data that suggest then when the SSRI is combined with cognitive behavioral therapy that can be even better than cognitive behavioral therapy alone in tic-related obsessive-compulsive disorder. So there may be a role for SSRIs in tic-related OCD. But that role does not seem to be as a solo agent but combined with cognitive behavioral therapy and nonmedication treatment. That really is the treatment of choice.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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And if OCD is considered as the primary diagnosis or interfering with successful treatment, that is unwilling to engage in competing responses due to associated obsessional content, treatment of OCD symptoms prior to engaging in further treatment for tics can also be an appropriate way to go.

References:

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.
McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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Tic disorders and anxiety or depression. Many youth with tic disorders have co-occurring mood and non-OCD anxiety disorders.

References:

McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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If anxiety or depression appear to be primary, unrelated to tics or interfere with treatment motivation and adherence, evidence-based treatment for anxiety or depression needs to be considered.

References:

McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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The presence of depression in patients with tic disorders has been positively associated with an earlier onset, greater severity, and a longer duration of tics.

References:

McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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Tic disorders and disruptive behaviors. Symptoms such as irritability, mood instability, problems with emotional regulation and anger control, impulse control and other disruptive behaviors are very common in youth with tics. These symptoms often stem from tics and/or tic impairment and could be managed by strategies that effectively address tics.

References:

McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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However, other strategies such as parent training, anger management, emotion regulation and mindfulness may also be required. If these strategies are ineffective, there are pharmacological interventions that can be helpful including topiramate.

References:

McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to treatment and management of youth with Tourette syndrome and tic disorders. Academic Press.

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Key points here. Decreased response rates to SSRIs have been observed in children with tic-related OCD. CBT with or without SSRI is considered first-line treatment in tic-related OCD.

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The presence of depression in patients with tic disorders is positively correlated with earlier onset, greater severity, and longer duration of tics. Irritability, mood instability, emotional dysregulation, and problems with impulse and anger control are common in youth with tic disorders.

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Next Section

06. Overview of Treatment for Tic Disorders

Learning Objectives:

After completing this activity, the learner will be able to:

Perform a thorough evaluation of tic disorders in children and adolescents.
Identify evidence-based treatments for children with tic disorders and determine the most suitable for each patient.
Apply appropriate pharmacologic strategies to optimize outcomes for children with tic disorders.

Original Release Date: April 1, 2023

Review and Re-release Date: March 1, 2024

Expiration Date: April 1, 2026

Expert: David Rosenberg, M.D.

Medical Editor: Paz Badía, M.D.

Relevant Financial Disclosures:

None of the faculty, planners, and reviewers for this educational activity have relevant financial relationships to disclose during the last 24 months with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Contact Information: For questions regarding the content or access to this activity, contact us at support@psychopharmacologyinstitute.com

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Participants must complete the activity online during the valid credit period that is noted above.

Follow these steps to earn CME credit:

View the required educational content provided on this course page.
Complete the Post Activity Evaluation for providing the necessary feedback for continuing accreditation purposes and for the development of future activities. NOTE: Completing the Post Activity Evaluation after the quiz is required to receive the earned credit.
Download your certificate.

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This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Medical Academy LLC and the Psychopharmacology Institute. Medical Academy is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation Statement

Medical Academy designates this enduring activity for a maximum of 1.50 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.