**4. Initial treatment considerations**

The critical first step in making treatment decisions in patients with tics or GTS is select the most appropriate target symptoms, the ones causing the most problemsin a patient's daily functioning. In one patient it maybe the tics themselves, in another it may be comorbid ADHD or OCD and in another it may be a combination of targets. Because psychosocial stresses can worsen symptoms, it is important to probe for these and consider interventions such as individual or family counseling. For patients with mild symptoms, educational and psychological interventions may be sufficient to bringing down symptoms to a tolerable

5. Anterior cingulate circuit: is part of limbic system and is associated to silence, apathy and tics. This circuit is originated in anterior cingulate gyrus and connects with ventral striatum, which is formed by olfactory tubercle, nucleus accumbens, caudate and putamen. Moreover, the striatum receives additional inputs of hippocampus, amygdala

Although the hypothesis of neural circuit was developed for tics and movement disorders, it is possible that this fundamental principle works for limbic and cognitive aspects. Gangliobasal outputs to frontal lobe via thalamus provide an anatomical substrate for the production of simple and complex tics and compulsions. Thus, abnormal activation of the motor cortex via thalamocortical circuit can cause motor and vocal tics. Abnormal activation of the supplementary area and gyrus cinguli can cause complex tics. Abnormal activation of

Striatum has three anatomical divisions: caudate, putamen and ventral striatum or limbic29. It has bony neurons with the inhibitory neurotransmitter GABA and another subgroup which uses substance P and dynorphin. Striatum projects to globus pallidus and substantia nigra pars reticulata30. By the way, neurons with encephalin projects to external globus

Boneless interneurons are divided into five subgroups: cholinergic and GABAergic neurons expressing parvualbumin; those expressing somatostatin; neuropeptide Y; nicotinamide

There are two different striatal pathways: one is direct and projects to the internal pallidus globus and substantia nigra pars reticulata; and the indirect going to the external globus pallidus. Both are inhibitory and mediated by GABA and neuroactive peptide. Integration of pathways inhibitory direct and indirect excitatory takes place at the internal globus pallidus and substantia nigra pars reticulata. Internal globus pallidus projects to thalamus

The effects of facilitation played by the direct route or suppression maintained by the indirect on the outputs of the thalamus to the cortex influences movement and cognitive processing. Deinhibition of thalamic neurons results in hyperexcitability of the projections

The critical first step in making treatment decisions in patients with tics or GTS is select the most appropriate target symptoms, the ones causing the most problemsin a patient's daily functioning. In one patient it maybe the tics themselves, in another it may be comorbid ADHD or OCD and in another it may be a combination of targets. Because psychosocial stresses can worsen symptoms, it is important to probe for these and consider interventions such as individual or family counseling. For patients with mild symptoms, educational and psychological interventions may be sufficient to bringing down symptoms to a tolerable

and entorhinal cortex.

**3.1.1 Stratium** 

orbitofrontal cortex can cause compulsions.

adenine dinucleotide phosphatase and nitric oxide31.

**3.1.2 Striatotalamhic and thalamocortical tracts** 

from the thalamus to the motor cortex leading to tics.

**4. Initial treatment considerations** 

pallidus and subthalamic nucleus.

through inhibitors GABA fibers.

level. Clinicians should remember that tics characteristically wax and wane in severity, so sometimes just waiting for some period of time can result in a lessening of tics and avoid medication use or increases.

Tics that interfere with school or other daily activities or are disabling because of social embarrassment, physical discomfort or self-injury must be treated. Tic-suppressing medications should be dosage titrated to identify the lowest one that will produce resolution of disability.
