Significant Tic Reduction in An Otherwise Treatment-Resistant Patient with Gilles de la Tourette Syndrome Following Treatment with Nabiximols
2 Max Planck Institute for Human Cognitive and Brain Sciences, Stephanstraße 1a, Leipzig 04103, Germany
2 Max Planck Institute for Human Cognitive and Brain Sciences, Stephanstraße 1a, Leipzig 04103, Germany
Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Early anecdotal reports and preliminary studies suggested that cannabinoid-based medicines such as delta-9-tetrahydrocannabinol (THC) are effective in the treatment of Gilles de la Tourette syndrome (TS). We report a single case study of a patient with otherwise treatment-resistant TS successfully treated with nabiximols. Our patient was a 22-year-old male suffering from severe and complex TS. Treatment with nabiximols was commenced at a dose of 1 puff/day (= 100 μL containing 2.7 mg THC and 2.5 mg cannabidiol (CBD)) and slowly increased up to a dosage of 3 × 3 puffs/day (= 24.3 mg THC and 22.5 mg CBD). Several clinical measures for tics, premonitory urges, and global impairment were acquired before and after two weeks of treatment. Treatment with nabiximols resulted in major improvements of both tics and premonitory urges, but also global impairment and health-related quality of life according to all used measurements without causing relevant adverse effects. Our results provide further evidence that treatment with nabiximols may be effective in the treatment of patients with TS. Given the positive response exhibited by the patient highlighted in this report, further investigation of the effects of nabiximols is proposed on a larger group of patients in a clinical trial setting.
Gilles de la Tourette syndrome (TS) is a disorder defined by the presence of multiple motor tics and at least one vocal tic. TS can be found in about 1% of the general population [1,2], and is three to four times more prevalent in males than in females [3,4,5]. Despite the fact that the range of treatments available for tic disorders and TS is gradually expanding, treatments are often ineffective or cause significant side effects . Therefore, there is an unmet need for more effective treatment options which cause fewer side effects and could potentially benefit otherwise treatment-resistant patients. Early anecdotal reports of successful self-medication with cannabis [7,8] provided evidence for an alternative mechanism of drug action that involves the central endocannabinoid system. Accordingly, cannabinoid-based medicine (CBM) such as delta-9-tetrahydrocannabinol (THC) has been suggested as such an effective new treatment strategy for patients with TS [9,10]. Nabiximols is a plant extract from Cannabis sativa L. containing THC and cannabidiol (CBD) at a 1:1 ratio. Anecdotal reports as well as preclinical data have provided some evidence that nabiximols may be more effective and better tolerated than pure THC, since CBD possesses its own effects  and mitigates the unwanted psychotropic effects of THC . Nabiximols is formulated as an oromucosal spray and is partly absorbed sublingually, resulting in reduced first pass effects, faster absorption, accelerated onset, and stronger effect compared to orally administered pharmaceutical products such as pure THC . To date there is only one published case study of a 26-year old male patient suffering from severe, otherwise treatment-resistant TS who improved significantly on nabiximols treatment . In the light of this new development, further evidence is needed to judge the efficacy of this treatment route. To shed more light onto cannabinoid treatment of TS, we report a further case study of a 22-year old German patient treated with nabiximols.
2. A Case of Severe TS
Our patient is a 22 years-old male who lives in Germany. The patient has a family history of attention deficit/hyperactivity disorder (ADHD) and depression on the mother’s side, as well as a family history of tics from both parents. He reached all these developmental milestones in a timely fashion and suffered from meningitis and otitis media at the age of six years. He started exhibiting symptoms of ADHD and tics as early as elementary school. Despite his increasingly disturbing tics, he managed to finish nine years of high school and start an apprenticeship in a nursing program. However, due to further worsening of his tic severity, he was incapacitated and unable to finish his degree or to start another internship or training program. He presented in our clinic for the first time at age 21 with severe complex vocal tics such as pronounced coprolalia, echolalia and spitting, as well as severe complex motor tics such as copropraxia including touching himself or others, and self-injurious behaviors such as punching himself in the head as well as punching his father. Apart from the tics, the patient suffered from a number of comorbid symptoms and conditions such as obsessive-compulsive behaviors (need for symmetry, just-right-feeling), ADHD, sleep problems, flight anxiety and pathological gambling. The pathological gambling had eventually led to petty crime, upon which the patient had been convicted to a short prison sentence. During his time in prison, he had been physically attacked by his inmates because of his tics and needed to be transferred to a single cell. The severity of his TS pushed the patient to seek various available pharmacological treatments (e.g., haloperidol, risperidone, aripirazole, clonidine, methylphenidate, atomoxetine, fluphenazine, pramipexole) alone or in combination with different drugs at one time. All treatments were either ineffective or caused intolerable side effects. The patient had no relevant history of drug use.
3. Treatment with Nabiximols
We initiated treatment with nabiximols (Sativex®, GW Pharma limited, Cambridge, CB24 9BZ, UK) at a dose of 1 puff per day (= 100 µL containing 2.7 mg THC and 2.5 mg CBD) and slowly increased up to a dosage of 3 × 3 puffs per day (= 24.3 mg THC and 22.5 mg CBD). Clinical assessments were carried out twice, once before treatment with nabiximols and once after two weeks of a stable dose of 3 × 3 puffs per day. The following instruments used included: (1) the total tic score (TTS) of the Yale Global Tic Severity Scale (YGTSS) , Tourette Syndrome Symptom List (TSSL) , and Modified Rush Video-Based Tic Scale (MRVS)  for tics; (2) the Premonitory Urge for Tics Scale (PUTS)  and Global Clinical Impairment (GCI) for premonitory urges; (3) GCI and the global score (GS) of the YGTSS for global impairment; and (4) the GTS-Quality of Life (GTS-QOL)  and the Visual Analogue Scale for satisfaction of the GTS-QOL (GTS-QoL-VAS) for health-related quality of life.
Treatment with nabiximols resulted in an improvement of overall tic severity by 22.2% (YGTSS-TTS: pre = 45, post = 35) and 58.8% (MRVS: pre = 17, post = 7) according to examiner’s assessments, and by 62.9% according to the patient’s self-assessment (TSSL: pre = 89, post = 33). The improvement in YGTSS increased further when disease-related burden was included (35.2% YGTSS-GS: pre = 85, post = 55). Accordingly, GCI exhibited an improvement of 50% (pre = 80, post = 40). Using two different measurements for premonitory urges, we found substantial improvement as well (35.3% PUTS: pre = 34, post = 22, 38.5% GCI for PU: pre = 65, post = 40). However, the most predominant effects were observed for quality of life, which exhibited improvements of 78.4% and 70% according to GTS-QOL (pre = 51, post = 11) and GTS-QOL-VAS (pre = 50, post = 85), respectively. All results are summarized in Table 1 and illustrated in Figure 1 . Treatment with nabiximols was well-tolerated by the patient and no noteworthy side effects were encountered.
Symptom improvement with nabiximols. For GTS-QOL-VAS a lower score represents better quality of life; for all other scales a higher score is better. Abbreviations: YGTSS-TTS = total tic score of the Yale Global Tic Severity Scale (range: 0–50), TSSL = Tourette Syndrome Symptom List (range: 0–336), MRVS = Modified Rush Video-Based Tic Scale (range: 0–20), PUTS = Premonitory Urge for Tics Scale (range: 0–36), GCI for PU = Global Clinical Impairment for premonitory urges (range: 0–100), YGTSS-GS = Global scale of the Yale Global Tic Severity Scale (range: 0–100), GCI = Global Clinical Impairment (range: 0–100), GTS-QOL = Gilles de la Tourette Syndrome-Quality of Life Scale (range: 0–100), GTS-QoL-VAS = Visual Analogue Scale for satisfaction of the GTS-QOL (range: 0–100).
Clinical measurements before and after treatment with nabiximols.
|Symptom||Scale||Baseline||Follow-Up after 2 Weeks||Percentage Improvement|
|GCI for PU||65||40||−38.5%|
|Quality of life||GTS-QOL||51||11||−78.4%|
a For GTS-QOL-VAS a positive percent change indicates improvement; for all other scales a negative change indicates improvement. Abbreviations: YGTSS-TTS = total tic score of the Yale Global Tic Severity Scale (range: 0–50), TSSL = Tourette Syndrome Symptom List (range: 0–336), MRVS = Modified Rush Video-Based Tic Scale (range: 0–20), PUTS = Premonitory Urge for Tics Scale (range: 0–36), GCI for PU = Global Clinical Impairment for premonitory urges (range: 0–100), YGTSS-GS = Global scale of the Yale Global Tic Severity Scale (range: 0–100), GCI = Global Clinical Impairment (range: 0–100), GTS-QOL = Gilles de la Tourette Syndrome-Quality of Life Scale (range: 0–100), GTS-QoL-VAS = Visual Analogue Scale for satisfaction of the GTS-QOL (range: 0–100).
Soon after the follow-up visit, the patient stopped attending further consultations. Therefore, little can be said about further compliance and the long-term effects of nabiximols in this individual case.
Tics usually follow a course of waxing and waning, therefore symptom improvement can never be reliably linked to a medication effect looking at a single case. However, in the case of our patient, who was incapacitated by his tics for a prolonged period of time, spontaneous substantial improvement was very unlikely to occur. Since this was an open trial, placebo effects cannot be distinguished from the medication effect. Still, we would not assume a large placebo effect in an otherwise treatment-resistant patient. Another limitation is that our patient was severely ill with a number of comorbid conditions and was thus phenotypically quite different from patients with a more common presentation of TS, which might limit the generalizability of our findings. In this study, we did not assess psychiatric comorbidities because at the time of treatment, tics were the core and most troublesome symptom of our patient and, therefore, treatment was initiated to reduce tics.
Our case study is completely in line with another recent case report  and provides further evidence suggesting that treatment with nabiximols may be effective in the treatment of patients with severe and otherwise treatment-resistant TS. Therefore, our results corroborate recent findings in further open uncontrolled case studies [7,8,20,21,22,23] and small controlled clinical trials [9,10] reporting beneficial effects of CBM such as cannabis and THC in this group of patients. From currently available data, it is suggested that CBM may improve not only tics, but also psychiatric comorbidities including ADHD symptoms [7,20,23], obsessive-compulsive behavior [20,23], self-injurious behavior , impulse control , hypersexuality , as well as concentration and visual perception . In this study, we concentrated on the treatment of tics and, therefore, did not assess behavioral problems. However, we found that the most predominant treatment effect was an improvement in the patient’s global impairment and quality of life. Therefore, it could be speculated that treatment with nabiximols in this patient resulted not only in an improvement of tics, but of comorbidities also. Comparable to other reports of treatment with CBM [7,20,23], our patient also experienced an improvement of premonitory urges during treatment with nabiximols. This is remarkable, since on the one hand the patient reports indicate that premonitory urges are perceived as the most troublesome symptom of the disease , but on the other hand an open uncontrolled study suggested that well-established treatment with antipsychotics such as aripiprazole improve tics, but not premonitory urges .
So far, there are no large controlled studies available investigating the effects of CBM in patients with TS or comparing the effects of CBM and antipsychotics or different CBM in TS. Given the positive response exhibited by the patient highlighted in this report and under the above-mentioned limitation, further investigation of the effect of nabiximols is strongly suggested. To properly investigate a treatment effect, a controlled clinical trial in a larger group of patients is called for. Therefore, our group is currently preparing a randomized multi-centre double-blind placebo controlled trial with 96 patients to investigate the efficacy and safety of nabiximols in the treatment of adults with chronic tic disorders (CANNA-TICS, EudraCT number: 2016-000564-42).
Our case study suggests that treatment with nabiximols may be effective in patients with otherwise treatment-resistant severe TS. Large clinical trials are called for to further examine this hypothesis.
K.M.V. treated the patient and provided all relevant clinical records. A.K. wrote the first draft of the manuscript. E.J. edited and finalized the manuscript.
Conflicts of Interest
The authors declare no conflict of interest.
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CBD for Tourette’s
Tourette Syndrome, also commonly called Tourette’s Disorder, is one of three types of tic disorders. Tic disorders are characterized by involuntary movements and vocalizations (“tics”), and a tic disorder is diagnosed as one of the three types according to the type of tics present and the length of time they have been present. Tourette’s involves at least two motor tics and one vocal tic that occur for more than one year. Both motor and vocal tics can range from being very mild and not noticeable, such as blinking or sniffing, to being large and disruptive, such as jumping or shouting.
10 Best CBD for Tourettes in 2022
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Around ten percent of people with Tourette’s experience complex vocal tics such as swear words. Most Tourette’s cases involve mild tics and are easy to manage, but it can become more complicated as the complexity and scale of the tics increases. When tics interfere with an individual’s normal social functioning, such as at school or work, they may seek treatment or therapy. It’s preferred to use a treatment that does not cause side effects or is unlikely to cause side effects. Speech therapy and behavior modification therapy are two such available treatments, and some medications are also available. However, since these medications pose a risk of some undesirable side effects, many people have become interested in CBD as an alternative. More information in our guide down below.
Safety of Using CBD for Tourette’s
Using CBD for Tourette’s is very unlikely to cause any side effects, and the treatment has been studied for more than forty years with very positive results. If CBD appeals to you as a potential treatment for you or a loved one with Tourette’s, discuss this option with your doctor and use our list of the ten best products as a reference to find high-quality CBD.
Benefits: How Does CBD Oil Treat Tourette’s?
People who use CBD for Tourette’s experience a -+few main benefits that can greatly improve their quality of life and ability to function socially.
- Reduced frequency and severity of tics – The most obvious reason to use CBD for Tourette’s is to treat and reduce tics. Both motor and vocal tics can be reduced by using CBD, but the reduction of motor tics seems to be more significant. The greatest reduction is in the frequency of the tics, but the severity or “violence” of the tics may also be reduced. While the reason for this effect is not understood, it is well documented that it does happen, and some individuals even have tics disappear when they use CBD.
- Improved sleep – Tourette’s often interferes with a person’s quality of sleep, particularly if they experience severe tics during the night. CBD can improve the sleep of Tourette’s patients both by reducing tics and by making it easier to relax and sleep well. In fact, the use of CBD for sleep is common even among people without medical conditions. – Obsessive-compulsive disorder (OCD) often occurs alongside Tourette’s. The compulsions and intrusive thoughts that are characteristic of many OCD cases can be improved with the use of CBD, which has a positive effect on mental health in general.
- Improved emotional and mental state – People with Tourette’s, especially children with Tourette’s, often feel sudden anger or experience outbursts of aggression. CBD is, for many people, very soothing and helps to regulate mood. The aggression that occurs in Tourette’s can be greatly improved with CBD treatment.
How to Use CBD for Tourette’s Syndrome?
The type of CBD that should be used for Tourette’s depends on the patient’s:
- Age – The laws regarding cannabis use in minors are often different from those for adults, so depending on the age of the patient and the location you live in, there may be different restrictions. Adults may choose to use CBD products that also include THC, for example, which is often not an option for minors.
- Symptoms – The dosage may depend on the size of the individual as well as the severity of symptoms. Minor tics may disappear with a lower dose of CBD than what is required for more severe tics.
- Personal preferences – CBD oil, edibles, and vape are three common types of CBD products. They all take different amounts of time to take effect, last for different amounts of time, and give a different experience. People who dislike the taste of cannabis may prefer to avoid CBD oil, for example, which takes effect quickly but is used by placing it directly in the mouth. Edibles may be best for improving sleep, as they tend to have the longest-lasting effects.
More choices available
What to Consider When Buying Oil for Tourette’s?
Your CBD treatment for Tourette’s should be personalized to your tics and your experience, so there are some factors to consider to make the usage safe for you.
- Quality: In the United States, cannabis products are not regulated by the FDA, so there is no guarantee of the quality or even of the accuracy of the label. Third-party companies can perform testing to verify that a product is high-quality and free from contaminants. Choose a product from our top ten list or another tested product to ensure that it is safe to use.
- Type of cannabis: If you are an adult in an area that allows the use of THC, you may consider full-spectrum CBD products, which contain enough THC to have a psychoactive effect. Some people simply enjoy this effect, and some believe that cannabis compounds are more effective when used together, so THC and CBD may work best as a pair.
- Legality: Finally, you should consider the cannabis regulation laws in your area. CBD is legal in most states, but not all, and some countries around the world also do not allow its use. Make sure you know the laws that apply to you before buying any CBD products.
Tourette’s is a condition that can affect the social function, sleep, and emotional state of those affected by it to a severe degree. Natural and safe treatments like CBD can offer relief from symptoms and improve the lives of patients. It reduces tics, improves sleep quality, and improves the emotional state in many people who use it. Before starting CBD for Tourette’s, discuss the treatment with your doctor. They will be able to advise you on any potential interactions with other medications or conditions. When you have a safe treatment, plan laid out, use our ultimate guide and unbiased reviews of the best products to find an effective, high-quality option.
Cannabinoid Oil And My Son’s Tic Disorder
Cannabinoid (CBD) oil has been a godsend since I found out my son was diagnosed with a tic disorder.
In late October of 2016, my 7-year-old son, Lincoln, was diagnosed with Transient Tic Disorder. It’s fairly easy to say that this moment shook me like I’ve never been shook before. I have never been so scared in my life! I’m sure all fathers out there have experienced the hopelessness of having a sick child. It’s excruciating and overwhelming.
Around late August, I’d noticed Lincoln had started this heavy, exaggerated blinking. I didn’t think anything of it, initially, as I used to do the same thing as a kid…and still do occasionally. Back in the day, my parents thought it was some strange habit I’d picked up. Within a few weeks, Lincoln’s blinks had increased in rate and exertion. He’d also started rolling his eyes in really pronounced ways…sometimes so hard that he’d turn his head to the side.
Then, almost suddenly, he was experiencing these episodes that were like seizures. His eyes were rolling back in his head, his tongue would go limp or roll in his mouth. His face would grimace. His hands, feet and limbs would twitch erratically. And he would make these noises…groans, growls and moans. Sometimes he’d whistle or repeat words during these spells.
The episodes would last between 5 and 45 minutes. It was painful to watch. Especially, when he’d come out of the episodes with no recollection of what he’d just experienced. He could not hear us calling his name or feel us holding him while he endured these episodes. He’d snap out of them confused, exhausted and in physical pain.
From September to November, we’d made countless trips to the ER and doctor’s appointments, including spending Thanksgiving in the hospital Epilepsy Monitoring Unit. We were relieved that seizures had been ruled out. But, the thought that the tics were causing this much chaos was unnerving. We also had to remove Lincoln from the school bus and set up a treatment plan with his school, as he was sensitive to loud noise, bright lights and rapid movement. We were also advised that if the motor and vocal tics continued for a year, Lincoln would be diagnosed with Tourette’s Syndrome.
During this entire process, we drastically altered the family diet, eliminating dairy, white sugar and taking meat out of the house, except for one meal on the weekends as sort of a cheat day. We also started a daily essential oil regimen, using doTERRA oils. The Frankincense oil was a major support . Overall, we saw some healthy results and improvement from these changes, especially regarding his ability to sleep soundly.
By this time, I’d already done extensive research on CBD oils and the benefits of medicinal Cannabis. I was strong in my belief that adding the CBD oil would be the completion of our treatment regimen. So, after some convincing of his mom, I ordered the best CBD oil I found during my research. I’m so elated to learn that I was correct.
Lincoln takes one veggie-cap (15 drops) of CBD oil a day. The facial tics, eye rolls and motor tics have essentially dissipated. He has not had an elongated episode in almost two months. His teachers have stated that they have really noticed a difference as well. I couldn’t be happier! An added bonus of not having my son on some medication to treat his symptoms and add toxins to his system, is that the CBD oil was half as much in cost and four times the usage.
I’m a pretty private person, so not many people know the pain and torment that my family has endured throughout this process. I also fought with myself to even share this story. But, I simply could not deny the sheer joy of the results that my son has seen with the use of CBD oil.
I say all that to say this. I’ve never been a huge proponent of legalizing marijuana, as I don’t smoke it. I’ve really just had a “live and let live” kind of approach to it. Now, that I’ve had the benefits of cannabis/hemp directly affect my family, I truly feel that there is a need to treat with what we have been naturally given.