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Figure 4 . Dystonia .
Figure 4A . Acute rheumatic torticollis .
Figure 4B . Medicationinduced dystonia .
James Heilman MD / CC BY-SA 3.0 / bit . ly / 34xj15r seminars , talks and other activities ; and other services . In this regard , directing a patient to the TSAA is worth considering as part of a comprehensive management plan . The TSAA is also able to send further information to GPs .
Psychological intervention and / or assessment
There is frequently a role for psychological intervention in the management of tic disorders and associated behavioural difficulties . Further , an educational assessment is often helpful because of the frequent presence of learning difficulties and attentional problems .
There is a growing evidence base for behavioural treatments , including a manualised and empirically evaluated program that incorporates habit reversal training ( HRT ), namely Comprehensive Behavioural Intervention for Tics ( CBIT ). 23 The program is based on the hypothesis that tics are at least partly maintained by reductions in the ‘ premonitory urge ’ following tic occurrence . Premonitory urges are typically uncomfortable sensations that often precede tics . Empirical data and patient reports suggest that tics serve to reduce these unpleasant phenomena , thus strengthening the probability of engaging in tics . 24 Over time , this urge – tic – relief cycle becomes automatic and occurs outside the awareness of the patient . HRT , one component of CBIT , was developed to counter this .
CBIT is a multicomponent behavioural intervention that teaches patients to manage their tics by using three procedures : awareness training , competing response training and social support . During awareness training , patients are taught to carefully describe each tic and PAGE 44
Tic disorder
Psychoeducation
Presence of tics but no indication for treatment
Presence of tics but comorbid disorder ( s ) have treatment priority
Indication for treatment of tics , with preference for ( and availablilty of ) behavioural treatment
No
No
No
Tics still with indication for treatment
Indication for treatment of tics , with preference for pharmacological treatment
Figure 5 . Decision tree for the management of GTS .
Yes
Yes
Yes
Yes
Tics still with indication for treatment
Monitoring
Treatment of comorbid disorder ( s )
Behavioural therapy ( HRT , CBIT and ERP )
Pharmacotherapy
Yes
Yes
Symptoms or indications Treatment
Combination of pharmacotherapy and behavioural therapy
Combined pharmacotherapy with different agents
Yes
Alternative therapies in specialised centres ( DBS , cannabinoids and botulinum toxin , among others )
Nature Reviews / Disease Primers
If GTS is suspected , diagnosis needs to be confirmed by considering other tic disorders and carrying out the indicated investigations . If symptoms are not distressing and / or causing dysfunction , supportive therapy ( for example , psychoeducation ) is recommended . If symptoms are distressing , pharmacological or non-pharmacological interventions should be given . However , if comorbid conditions are present and more impairing than GTS , they should have treatment priority . When treatment is successful , monitoring remains essential . Solid arrows indicate the next level of evaluation or treatment ; dashed arrows indicate alternation between two treatments . CBIT , comprehensive behavioural intervention for tics ; DBS , deep brain stimulation ; ERP , exposure and response prevention ; HRT , habit reversal therapy .
Image reproduced with permission Nature Reviews Disease Primer .