Treatment principles for Tourette syndrome

NOTE: At present, this page does not contain treatment suggestions for everyone. It is part of a note I wrote for one patient, so it may not pertain to anyone else. Nevertheless, it does summarize some of my current thoughts about treatment. Treatment changes almost daily--yesterday I saw news about a company applying for a patent for use of GABA aminotransferase inhibitors for treatment of TS--so this page may become dated very quickly.
Also please note this patient was an adult, so medication doses given are for an adult.
/KJB, 12 Feb 2012

Treatment for tics

Choice of tic treatment begins with whether to treat at all. This is purely a symptomatic risk:benefit trade-off. Since this person's tics are causing pain and embarrassment, treatment is very reasonable, but is not essential. Options for tic treatment are numerous and include:
  1. **CBIT (Comprehensive Behavioral Intervention for Tics)**. About ten 60- to 90-minute sessions. Any psychologist who has experience doing exposure and response prevention for OCD can learn to do this. The Tourette Syndrome Association ( has training and information for psychologists, or see my web page on the subject. It is approximately as effective as our most effective medication—on average across subjects—at least for patients similar to those who are eligible for randomized controlled trials of medications or psychotherapy.
  2. The most effective medications at this time are antipsychotics. The best tolerated in TS patients in my experience is aripiprazole, usually 5-30mg/day in adults.
  3. Usually before trying antipsychotics I try something else due to the very low but nonzero risk of tardive dyskinesia with antipsychotics.
    1. clonazepam 0.5-4mg bid (may also help with anxiety; most common side effect is sedation)
    2. guanfacine 0.5-2mg p.o. t.i.d. (or Intuniv slow release 4mg once daily) for which lightheadedness on standing and dry mouth are common side effects but sedation is usually less than for clonazepam. This has the advantage of being proven to help with ADHD as well.
    3. tetrabenazine (about 12.5mg bid to 25mg tid), a presynaptic monoamine depleter, is probably as effective as antipsychotics for tics but not as well tolerated as aripiprazole in the short run. The advantage is that it has no known risk of tardive dyskinesia. It may be especially useful for patients who are expected to have many months to years of tics that are fairly severe or inadequately responsive to other non-antipsychotic options. It’s expensive but may be covered by insurance, and there is a patient assistance program based on financial need.

Treatment for OCD in people with tics

OCD treatment options are:
  1. Exposure and response prevention (E/RP, a type of behavior therapy)
  2. High-dose SSRIs (e.g. fluoxetine 40-80mg/d)
  3. Adding any antipsychotic to high-dose SSRIs is a common option.
  4. In patients with tics, risperidone is sometimes used as monotherapy for OCD+tics.

Treatment for ADHD in people with tics

ADHD treatment options include:
  1. Stimulants are the most effective treatment for ADHD. Contrary to clinical lore and the package inserts, it is now abundantly clear that methylphenidate actually improves tics, on average. In fact, almost as many TS patients have been treated with methylphenidate in randomized controlled trials as with second-generation antipsychotics, and all trials showed benefit for tics (though effect sizes were smaller than for antipsychotics). Amphetamine and amphetamine derivatives may be different from methylphenidate, as there is minimal information about their safety or efficacy in tic patients.
  2. guanfacine also helps ADHD including in people with tics, and helps tics.
  3. desipramine has also been shown to be efficacious for both ADHD and (to a lesser extent) tics in patients with TS and ADHD.

Treating this particular patient.

For this patient, I would probably start with CBIT if possible. A college psychology department probably has a low-cost option for treatment by a licensed psychologist or a clinical PhD student or intern. Any of those would be excellent options. If a medication is desired, I’d probably start with methylphenidate, yes for the tics, but it will likely also help with the ADHD symptoms. Alternatively, I’d use guanfacine. If more effective anti-tic benefit is needed, e.g. if tics get worse or don’t respond to the above measures, I’d go to aripiprazole or tetrabenazine. I would also recommend treatment for OCD either with E/RP or with SSRIs or both. On average SSRIs don’t improve (or worsen) tics, but in some patients who need SSRIs for OCD or depression anyway they seem to help.


Black KJ: An evidence-based review of treatment efficacy in tic disorders: A report of the ANPA Committee on Research. Invited plenary lecture, 21st annual meeting, American Neuropsychiatric Association. Tampa, FL, 17-20 March 2010.