Beneath the tip of the iceberg: treatment of neuropsychiatric comorbidities in tic disorders.

While Tourette syndrome (TS) is defined by tics, comorbidities are very much part of the clinical presentation - 90% of patients having a least one associated condition, most prominently obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD), but also learning disabilities, anxiety, depression, rage outbursts, autism spectrum disorder, sensory hypersensitivities, and sleep difficulties. Moreover, the associated symptoms often are more problematic than tics, or interact with the tics such that the different symptoms exacerbate each other, adding complexity to the clinical picture. Thus, to provide optimal care to patients with TS, it is essential that clinicians consider and address associated symptoms as part of their management. In this chapter, we review the treatment of the common neuropsychiatric comorbidities in TS, focusing especially on OCD and ADHD. We describe cognitive, behavioral, and pharmacologic interventions, with the aim of making these clear and applicable for the nonspecialist clinician. The goal is for clinicians to provide holistic care that includes understanding the impact of various symptoms and collaboratively prioritizing targets for intervention while favoring conservative approaches, in order to improve the quality of life of patients with TS.