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We wish to emphasize again that tic disorders are frequent, especially in children and adolescents (Tourette syndrome 1%, transient motor tic disorders 10–15%). Actual impairment and therefore need for treatment are notably less common, but because of the high susceptibility to further behavioral abnormalities, consultations of child and adolescent psychiatrists are not rare.

Tics usually respond well to pharmacological treatment or behavioral therapies. Combination therapy or even deep brain stimulation are only required in case of severe tics or several comorbidities. We described in our article the unsatisfactory evidence base for psychopharmacological therapy (1).

We are not aware that Tourette syndrome—even in patients with comorbid depression—is associated with an overly increased risk of suicide. In severely affected patients, distinct autoaggressive actions may occur, but these differ from suicidal acts (2).

We explicitly agree with Calia that medication treatment of compulsions has to be given at higher dosages and for a minimum of three months (3). It is also correct that medications have to be ruled out as the cause of tic-like movements. It is usually easy to differentiate tics from compulsive symptoms because of the typical course of tics. In patients with complex tics and compulsions, this differentiation may be more difficult. In our opinion, MRI is indicated only in patients whose findings are untypical (abnormal neurological findings on examination, lacking fluctuation of tics, absence of premonitory urge, inability to suppress tics).

We want to emphasize once more the importance of providing an elaborate and detailed psychoeducation and information of the caregivers and peers of the affected children and adolescents. Such measures can substantially contribute to preventing social withdrawal (which may even become social phobia) (4).

DOI: 10.3238/arztebl.2013.0285b

Prof. Dr. med. Andrea Ludolph, Klinik für Kinder- und Jugendpsychiatrie und
Psychotherapie, Ulm, andrea.ludolph@uni-ulm.de

Prof. Dr. med. Veit Roessner, Prof. med. Alexander Münchau
Prof. med. Kirsten Müller-Vahl

Conflict of interest statement

Prof. Ludolph has served as a consultant for, and has received reimbursement for travel costs from Shire Pharmaceuticals. She has received lecture honoraria from Janssen-Cilag, Medice Pharma, and Lilly as well as an unrestricted research grant from Novartis and has carried out clinical trials in cooperation with the Janssen-Cilag, Otsuka, Shire, and Boehringer Ingelheim.

Prof. Roessner has received payment for consulting and writing activities from Lilly, Novartis, and Shire Pharmaceuticals, lecture honoraria from Lilly, Novartis, Shire Pharmaceuticals, and Medice Pharma, and support for research from Shire and Novartis. He has carried out (and is currently carrying out) clinical trials in cooperation with Novartis, Shire, and Otsuka.

Prof. Münchau is serving on the advisory board of Merz Pharmaceuticals. He has received reimbursement of travel expenses and medical conference delegate fees from Merz Pharmaceuticals and Pharm Allergan, and Ipsen. He has received honoraria for preparing continuing medical educational events from Merz Pharmaceuticals, Pharm Allergan, Ipsen, Desitin, and GSK and honoraria for conducting clinical studies and a research project initiated by himself from Merz Pharmaceuticals and Pharm Allergan, and Ipsen.

Prof. Müller-Vahl has received financial support for research from the Lundbeck company and has carried out (and is currently carrying out) clinical trials in cooperation with Otsuka Pharma and Boehringer Ingelheim.

1.
Ludolph AG, Roessner V, Münchau A, Müller-Vahl K: Tourette syndrome and other tic disorders in childhood, adolescence and adulthood. Dtsch Arztebl Int 2012; 109(48): 821–8. VOLLTEXT
2.
Andover MS, Morris BW, Wren A, Bruzzese ME: The co-occurrence of non-suicidal self-injury and attempted suicide among adolescents: distinguishing risk factors and psychosocial correlates. Child Adolesc Psychiatry Ment Health 2012; 30:11. CrossRef MEDLINE PubMed Central
3.
Roessner V, Plessen KJ, Rothenberger A, Ludolph AG, Rizzo R, Skov L, Strand G, Stern JS, Termine C, Hoekstra PJ: ESSTS Guidelines Group. European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment. Eur Child Adolesc Psychiatry 2011; 20:173–96. CrossRef MEDLINE PubMed Central
4.
Marcks BA, Berlin KS, Woods DW, Davies WH: Impact of Tourette Syndrome: a preliminary investigation of the effects of disclosure on peer perceptions and social functioning. Psychiatry 2007; 70: 59–67. CrossRef MEDLINE
1.Ludolph AG, Roessner V, Münchau A, Müller-Vahl K: Tourette syndrome and other tic disorders in childhood, adolescence and adulthood. Dtsch Arztebl Int 2012; 109(48): 821–8. VOLLTEXT
2.Andover MS, Morris BW, Wren A, Bruzzese ME: The co-occurrence of non-suicidal self-injury and attempted suicide among adolescents: distinguishing risk factors and psychosocial correlates. Child Adolesc Psychiatry Ment Health 2012; 30:11. CrossRef MEDLINE PubMed Central
3.Roessner V, Plessen KJ, Rothenberger A, Ludolph AG, Rizzo R, Skov L, Strand G, Stern JS, Termine C, Hoekstra PJ: ESSTS Guidelines Group. European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment. Eur Child Adolesc Psychiatry 2011; 20:173–96. CrossRef MEDLINE PubMed Central
4.Marcks BA, Berlin KS, Woods DW, Davies WH: Impact of Tourette Syndrome: a preliminary investigation of the effects of disclosure on peer perceptions and social functioning. Psychiatry 2007; 70: 59–67. CrossRef MEDLINE

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