Kevin J. Black, M.D., one of the staff physicians at the Washington University Movement Disorders Clinic, is on the TSA's Physician Referral List. Some of you know him from our support group meetings. Here he answers some questions from our readers for general information. Since each person is different, you will want to contact your personal physician for specific medical advice.

Q: Some of our children have had severe constipation ("megacolon"), partly from
medications. Too many of us know our plumbers on a first-name basis. What can we do
about it?
A: First of all, it is true that several commonly used medications for treatment of TS can
cause constipation. The most likely offenders are drugs like clomipramine (Anafranil®),
imipramine, and nortriptyline, which are often prescribed for treating obsessions and
compulsions, depression, or attention deficit / hyperactivity. Dopamine antagonists such as
haloperidol (Haldol®) or pimozide (Orap®), usually prescribed for tics, can also cause
constipation. If there were a perfect pill to treat the problem you would already know it, and
most laxative-type drugs can cause their own side effects, some of them serious. So the
treatment approach should always start with the basics. One sensible approach might be as
follows. (1) If it doesn't cause any problems, ignore it. Some kids just go longer between
stools than others. (2) If the only problem is stopping up the toilet, try to get your child to
flush more than once while using the bathroom. (3) Drink lots of water. (4) Lots of fresh
fruits and vegetables. (5) Regular toilet times even if they say they don't need to go. (6) See
if there is an alternative medication that will work just as well but causes less constipation.
For instance, paroxetine (Paxil®), fluoxetine (Prozac®), fluvoxamine (Luvox®), and sertraline
(Zoloft®) are much less likely to cause constipation than clomipramine, and they work about
as well. (7) If none of this works there are medications to treat constipation but their side
effects should be discussed individually with your doctor before long-term use.

Q: How does Depakote help control rage in some TS patients? Have you had much
experience with it for that purpose? I know of one parent who swears by it and says her son
has been able to quit taking all of other meds.
A: Depakote® is a brand name for sodium divalproex, also frequently referred to as
valproate. It was originally marketed for treating seizures, but it has been proven to be very
effective for other conditions including manic-depressive illness. It is a relatively safe drug
overall though you should discuss side effects with your doctor before using it. There are
several reasons to think valproate might be effective for irritability or aggression. One open
study in 10 adolescents with "chronic temper outbursts and mood lability" showed good
benefit in all 10. However, there are no controlled studies of valproate in TS patients. This
means we are doing educated guessing here. Depakote® may be a very reasonable treatment
option for some people with TS and anger outbursts. However, there are other options. If rage
seems to follow predictable triggers, then specific treatment related to those triggers may be
the best first step. For instance, "time outs" or other behavioral treatments may help with
anger when not getting one's way. Behavior therapy or medications for OCD would be the
first choice if rage follows not being allowed to complete a compulsive ritual. Other
medications that have been tried for similar reasons in adolescents include neuroleptics (like
haloperidol), lithium salts, propranolol, and clonidine. In addition, a home behavioral
treatment plan may be considered whether or not medication is used.

Kevin J. Black, M.D.