A 35-year-old man comes to the office due to episodes of grunting, blinking, and squinting that last for a few moments at a time. His new girlfriend has noticed occasional episodes of these behaviors, especially when they argue. The patient had similar episodes during middle school, often associated with feeling stressed or anxious. Although he does not have distress regarding the movements, he agreed to be evaluated at his girlfriend's suggestion. The patient has no significant medical history. Family history is notable for obsessive-compulsive disorder in his father. Vital signs are normal and physical examination is unremarkable. Which of the following is the best next step in management?

Question

A 35-year-old man comes to the office due to episodes of grunting, blinking, and squinting that last for a few moments at a time.  His new girlfriend has noticed occasional episodes of these behaviors, especially when they argue.  The patient had similar episodes during middle school, often associated with feeling stressed or anxious.  Although he does not have distress regarding the movements, he agreed to be evaluated at his girlfriend's suggestion.  The patient has no significant medical history.  Family history is notable for obsessive-compulsive disorder in his father.  Vital signs are normal and physical examination is unremarkable.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d5d1_b4fb_bc81_47fa6c61e26a_MD0003_00 This patient's combination of motor (eg, blinking, squinting) and vocal (eg, grunting) tics with onset during adolescence is consistent with Tourette syndrome (TS). Management of TS depends on the degree of functional impairment and distress. Intervention is typically recommended only when TS symptoms interfere with activities or cause subjective discomfort. When tics are mild, infrequent, and do not cause distress, as in this patient, the first step should be providing counseling about TS and watchful waiting for symptom progression. Education should include discussion of the waxing and waning nature of tics, and the association between worsening of tics and stress. If symptoms worsen or cause distress, active treatment can be considered. When tics are severe, disabling, or distressing, treatment options include behavioral and pharmacological interventions. Behavioral therapy consists of habit reversal training in which the patient learns to substitute a voluntary movement that is incompatible with the tic. Pharmacological options include vesicular monoamine transporter 2 (VMAT2) inhibitors (eg, tetrabenazine), which are increasingly preferred as initial treatment; antipsychotic medications (eg, risperidone), which are associated with a risk of parkinsonism, tardive dyskinesia, and metabolic effects; and alpha-adrenergic agonists (eg, guanfacine, clonidine), which are helpful when comorbid attention deficit hyperactivity disorder or behavioral issues are present (Choices A, C, and D). Educational objective: Management of Tourette syndrome depends on the degree of functional impairment and distress. When symptoms are mild and do not interfere with activities, the appropriate first step is counseling and watchful waiting. References: Practice guideline recommendations summary: treatment of tics in people with Tourette syndrome and chronic tic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/31061208) Tourette disorder and other tic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/31727209)

A 35-Year-Old Man Comes to the Office Due to Episodes