Dr. Coffey, you are a leading expert in tics and Tourette’s syndrome. Can you give us some background on your special interest in these conditions? Dr. Coffey: I am the director of the clinical and research programs for tics and Tourette’s at NYU. Before that I was in Boston at McLean and Massachusetts General Hospitals. My interest in Tourette’s and tic disorders developed about 25 years ago, right after my medical training when I was working in a neurology clinic. I am particularly interested in the relationship between tic disorders and common comorbid conditions, such as ADHD and OCD.
That “unholy trinity” of OCD, ADHD, and tic disorder is a great challenge to many psychiatrists.Dr. Coffey: A colleague, Dr. Cathy Budman, found that if you look at kids who come to a Tourette’s clinic with explosive outbursts, they are much more likely to have this trio than kids without outbursts (Budman CL et al, J Am Acad Child Adolesc Psychiatry 2000;39(10):1270–1276). It is that combination of impulsivity and compulsivity that is so challenging.
Well, let’s break it down piece by piece, discussing these conditions as they relate to just tic disorder, and the relationship between the three. Let’s begin with OCD. Dr. Coffey: Sometimes complex motor tics and OCD compulsions can be difficult to differentiate, since both are related to urges to perform some type of activity or movement. I was involved in a study at Mass General in which we asked adults with OCD only, Tourette’s only, and a group with both OCD and Tourette’s to tell us about their repetitive behaviors. Then we developed a scale to rate what went on before (premonitory), during, and after the repetitive behaviors, in particular cognitive phenomena, such as a concern or worry, and sensory motor phenomena, such as a physical urge.
And what did you learn?Dr. Coffey: We found these adult patients could often differentiate their repetitive behaviors based on their premonitory experience or during the repetitive behavior experience. We found that OCD-only patients had cognitive phenomena, such as thoughts or worries, as you would expect, before their repetitive behaviors, while Tourette’s-only patients had sensory motor experiences—a physiologic urge that built up inside. And patients with Tourette’s plus OCD had both. And they could literally tell us with every single behavior whether it was a tic or a compulsion (Miguel EC et al, J Clin Psychiatry 1995;56(6):246–255). At the time, I had a graduate student who studied the same thing in children ages nine to 17, and while she never published the research, she found the same exact result.
So what do you do with that information?Dr. Coffey: The next step would be to think about appropriate treatment: for example, maybe we could treat the cognitive phenomena prior to repetitive behaviors with an SSRI, and the repetitive behaviors preceded by sensory motor experiences with tic suppressing medication such as alpha adrenergic agonists and antipsychotics. There are not a lot of studies looking at treatment for tics and OCD. But, generally, we will start with a trial of one SSRI, then switch to a second if the first one is not effective or is not tolerated, and then start to augment if necessary before finally switching to clomipramine (Anafranil). There is some data that augmentation with an antipsychotic is particularly helpful for the OCD in kids with the combination of these conditions (Goodman WK et al, J Child Neurol 2006;21(8):704–714).
And how does ADHD fit into this?Dr. Coffey: About half the kids who walk in the door to a Tourette’s clinic will have ADHD—not always diagnosed, depending on how old they are and how prominent the tics are (Mol Debes NM et al, J Child Neurol 2008;23(9):1017–1027).
And how do these three conditions relate in terms of course of illness?Dr. Coffey: The most recent evidence suggests that most kids’ tics will get better over time, but the comorbidities may not. Sometimes OCD gets better or may worsen after tics attenuate, but usually ADHD doesn’t go away. It sometimes changes from primarily hyperactive to maybe more inattentive for example, but it doesn’t stop. A 1998 study found that lifetime peak for tics was around age nine to age 11 (Leckman JF et al, Pediatrics 1998;102(1):14–19). There might still be some tics after that, but tic-related impairment, which is really the most clinically meaningful component, drops out considerably after puberty. So we think there is a phenomenon of tics getting better, and then OCD kicking in, and ADHD, if they have it, persisting (Spencer T et al, Child Psychol Psychiatry 1998;39(7):1037–1044; Coffey BJ et al, J Nerv Ment Dis 2004;192(11):776–780).
So if a patient has a tic disorder with one or both of these comorbidities, how do you decide what to treat?Dr. Coffey: I believe in the very simple approach of asking the parents, teachers, and especially the child: which is the most problematic or impairing? It is interesting that many times, especially with younger children, parents are more concerned about the tics than the kids are. We don’t treat tics unless they are getting in the child’s way functionally or causing the child distress, neither of which necessarily correlate with tic severity. Sometimes a child might appear to have very mild tics by standardized ratings, but in fact is in deep distress about it, and so we will go ahead and treat on that basis. So we start treating the most impairing symptom or comorbid disorder first, with the idea that if we can improve ADHD or OCD, the tics might indirectly get better.
Let’s say you get the comorbid condition under control, but the tics are still bothersome. Then what?Dr. Coffey: For treating tics, I use an algorithm that puts habit reversal therapy first. Then we try an alpha adrenergic agonist, clonidine (Catapres) or guanfacine (Tenex). After that, the standard of care is risperidone (Risperdal), but because of all of its side effects, my preference for the next step is aripiprazole (Abilify). If you still have problematic tics after that, you can combine an alpha adrenergic agonist with an atypical antipsychotic. Way down near the end of the list, I will try a typical antipsychotic, such as haloperidol (Haldol) or pimozide (Orap). There are much more experimental treatments, without much data, such as pramipexole (Mirapex), baclofen (Lioresal), botulin toxin (Botox). Way at the bottom of the algorithm is deep brain stimulation, but I would not recommend going around suggesting that to parents!
Tell us more about your first line choice, habit reversal therapy? Dr. Coffey: This is a type of cognitive behavior therapy that is terrific for tics. A recent study looked at 126 kids, randomized to either habit reversal therapy or the comparative treatment, which was supportive therapy, with unstructured psychoeducation. The habit reversal therapy was far superior to the supportive therapy with an effect size of 0.68, which is comparable to the best medicines that you can use—and there are no side effects (Piacentini J, JAMA 2010;303(19):1929–1937). It’s only been studied in kids age nine to age 17, but as long as a child has enough self-awareness, it should work. And, as it is manualized, (Woods, D et al, Managing Tourette Syndrome. Oxford, UK:Oxford University Press;2008) any good child CBT therapist can figure this out so you don’t have to go searching around for someone to do it.
How about stimulants for tics?Dr. Coffey: There’s an idea that stimulants aren’t good for kids with tics, but that’s just not true. If you go to the Physicians’ Desk Reference it still says that methylphenidate-based stimulants are contraindicated in the treatment of a child with Tourette’s or chronic tics, or even one who has a family history of these conditions. This is not the case for the amphetamines. This is amazing, considering the only head to head data we have shows that methylphenidate stimulants are better tolerated than the amphetamines in kids with Tourette’s and ADHD (Castellanos FX et al, J Am Acad Child Adolesc Psychiatry 1997;36(5):589–596).
So methylphenidate is a good choice for kids with comorbid tics and ADHD?Dr. Coffey: Yes. In the ‘90s there was a small study of kids with Tourette’s and ADHD that found a minor increase in tics in kids treated with methylphenidate. However, their ADHD was so much better that parents didn’t care about slightly more frequent tics. This group replicated the study in 2007 with the same results in a larger sample (Gadow KD et al, Arch Gen Psychiatry 1995;52(6):444–455;Gadow KD et al, J Am Acad Child Adolesc Psychiatry 2007; 46; 840–848). In 2002 we published the TACT Study, Treatment of Children with ADHD in Tic Disorders. This was a four arm trial with a clonidine alone arm; a methylphenidate alone arm; a methylphenidate plus clonidine arm; and a placebo arm. We found, as expected, that the kids on the combination of stimulant and clonidine did best in terms of both ADHD symptoms and tics. We were surprised to see that kids on methylphenidate alone not only saw their ADHD improve, but the tics got better too (Tourette Syndrome Study Group, Neurology 2002;58:527–536).
Is there anything new on the frontier for these kids?Dr. Coffey: There are some new clinical trials cropping up. A large group, called the Tourette Syndrome Association Clinical Trials Consortium, has been organized and is planning studies on “proof of concept” and potential tic suppressing medications with different mechanisms of action. I have to say the best advance in the last five years is proving that habit reversal therapy works. It has no side effects and kids and parents love it—what’s not to like? Next will be to consider trials with a combination of medication and habit reversal therapy, particularly for tics and the comorbid disorders. So this is a direction our energy will be going in.