Pregnancy in this 19-year-old German male with no family history of tic disorders was complicated by false labor starting at month 5. He was born on week 36 (weight: 2800 g, height: 50 cm) and was kept at the newborn ward for a 10-day observation period. His further development followed normal patterns and he learned to speak at 3 years. However, from this age on, he suffered from speech pathology issues including universal dyslalia and dysgrammatism. He received appropriate speech therapy for both conditions, resulting in symptom improvement. However, over the course of the treatment the patient started exhibiting a new symptom resembling a stuttering. Despite being directly targeted by speech therapy, this symptom showed no signs of improvement. At age seven, a first motor tic—mouth opening—was observed, followed by first simple vocal tics in the form of coughing and producing a “hm” sound. The patient’s speech therapist suspected a connection between the stuttering-like symptom and the patient’s tics and referred him to our specialty TS clinic for further evaluation, where he was initially seen in 2005 at the age of eight. At his initial presentation, the patient exhibited typical motor tics including tensing of hands, stomping, blinking, nodding, tensing of the upper body, and kicking. In addition, typical simple vocal tics such as animal noises were observed. Clinically relevant comorbidities were seen neither at the first nor at follow-up visits. The speech impairment was identified as a complex vocal tic in the form of a combination of early onset of palilalia and a vocal blocking tic, which phenotypically resembled a stuttering. Over the course of his childhood and adolescence, the patient remained in our outpatient clinic and was seen on a regular basis for medical management and further clinical consultations. The course of the vocal blocking tic followed the typical waxing and waning time course also observed in his other tics. Three speech therapies over three years remained without any improvement, which further validated the diagnosis of vocal blocking tics instead of primary stuttering. However, over the course of puberty, the patient’s tics and in particularly vocal blocking phenomena deteriorated further. As a result, his school performance decreased and he was at risk of having to repeat the eighth grade. Starting at age 9, the patient received a number of different medical treatments consisting of atypical antipsychotic medications including tiaprid (up to 900 mg/day), sulprid (up to 800 mg/day), risperidone (up to 1 mg/day), and aripiprazole (up to 30 mg/day). Over the years, the patient best profited from tiaprid treatment, although the effect was only mild. Combination with other antipsychotics did not lead to significant symptom improvement. Subsequently, tiaprid was increased to 900 mg. However, at age 14 dose needed to be lowered due to significant weight gain and 3 years later again (to 300 mg), when he developed acute dyskinesia. Finally, at the age of 19 years, the vocal blocking tic was by far the most disturbing tic and the patient was unable to hold a normal conversation for over a year. It could take him more than one minute to say one single word. The speech impairment depended highly on the situation: speaking to family members and friends was easier and more fluent, while speaking to strangers was barely possible. Understandably, these symptoms had a devastating influence on the patient’s everyday life, in particular social situations and performance at school. As a result of these difficulties, the patient withdrew from any social situations and reduced any outside activities, becoming more and more homebound. Academic performance was so poor that the patient was in danger of dropping out of high school without a degree.

At that time, the patient made the decision for treatment with CBM. As his insurance company had refused coverage of therapy costs with nabiximols, less expensive treatment with medical cannabis (based on a permission by the German federal opium agency) was initiated at a dose of 0.1 g vaporized medical cannabis (Bedrocan^®, Veendam, The Netherlands), containing 22% THC and 1% CBD) once daily and was increased to 0.6 g/day. At the 8 months follow-up and subsequent visits, the patient presented very much improved, he was able to converse with the doctors fluently, and he reported to be able to speak nearly fluently in most situations. Improvement also occurred in other tics, such as head nodding. The patient reported an effect onset at 5–10 min after administration that lasted typically up to one hour and a half. Although the drug effect dissipated after that, he usually experienced a significant tic reduction of about 70% including the blocking speech tics and a feeling of “being calmer” throughout the whole day. Over the course of the first few weeks of treatment, the patient used to experience a “high” after administration that completely disappeared later in treatment. No further side effects were reported.