Pandemic Tic-like Behaviors Following Social Media Consumption

WWC1 mutation drives dopamine dysregulation and synaptic imbalance in Tourette's syndrome

Tourette's syndrome (TS) is a major neurodevelopmental disorder characterized by childhood-onset motor and vocal tics. A W88C mutation in WWC1 gene is a notable risk factor for TS, but the underlying molecular mechanisms remain unclear due to the lack of suitable animal models. Here, we generate a mutant mouse line with human W88C mutation (W88CMut mice), which exhibits behavioral deficits similar to those observed in patients with TS, including repetitive motor behaviors and sensorimotor gating abnormalities. The W88C mutation leads to the degradation of kidney and brain (KIBRA) protein via a proteasomal pathway, evokes dopamine release in the dorsal striatum, and disrupts synaptic function through the dysregulation of Hippo pathway. Neuron-specific overexpression of wild-type WWC1 rescues synaptic and behavioral phenotypes in W88CMut mice. Together, this study not only provides a valuable mouse model for studying TS but also offers fresh insights into the molecular and synaptic mechanisms underlying neurodevelopmental abnormalities in TS.

When It's Not Tics: Functional Tic-Like Behaviors

Functional tic-like behaviors (FTLBs) are a manifestation of functional neurologic disorder that can be mistaken for neurodevelopmental tic disorders like Tourette syndrome. Much information was gained about FTLBs because of an outbreak of FTLBs spreading among adolescents and young adults via social media during the coronavirus disease 2019 pandemic. In comparison to neurodevelopmental tic disorders, FTLBs have an older age of onset, more abrupt symptom onset, and more complex tics as well as other features that would be atypical of Tourette syndrome. Although they do not respond well to standard treatment for neurodevelopmental tics, they are treatable with appropriate behavioral therapy.

Prevalence of mass social media-induced illness presenting with Tourette-like behavior in Germany between 2019 and 2021

Starting in 2019, in Germany the first well documented outbreak of mass sociogenic illness induced by social media (mass social media-induced illness; MSMI) occurred presenting with functional Tourette-like behaviors (FTB). This study aimed to provide first data on the prevalence rate of MSMI-FTB in Germany between 2019 and 2021 in the general population. We conducted a large-scale representative population survey in cooperation with the USUMA market and social research institute. Between August and December 2021, n = 2.509 people (mean age: 49.5 years, range: 16-95 years, n = 1.276 females) were randomly selected, visited in their households, interviewed, and asked to answer for themselves, but also for close family members (n = 6.744). Thus, in total, we received answers for n = 9.253 people. Probable MSMI-FTB was found in n = 33 individuals (mean age at onset: 30.5 years, n = 8 females). Based on strict criteria, the diagnosis of MSMI-FTB was considered highly likely in 16/33 individuals (mean age at onset: 25.6 years, n = 2 females) corresponding to prevalence rates of 0.17% (CIlower = 0.10, CIupper = 0.28) and 0.36% (CIlower = 0.25, CIupper = 0.50), respectively. This is the first large-scale, population representative study investigating the prevalence of MSMI-FTB in the general population in Germany between 2019 and 2021. Based on the prevalence rates found, MSMI-FTB is highly relevant for health economy. Accordingly, we suggest educating healthcare professionals and the general public to avoid misdiagnosis and inefficient treatment.

A Critical Examination of the Clinical Diagnosis of Functional Tic-like Behaviors

BACKGROUND

Since the COVID-19 pandemic, movement disorder clinics have seen an increase in patients with an unusual type of tic-like symptoms: young adults with abrupt onset complex behaviors. It was quickly suspected that these patients suffered from functional neurological symptoms, later named Functional Tic-Like Behaviors (FTLB). Subsequent research on the differential diagnosis between FTLB and tics has been substantial and led to the development of diagnostic checklists.

OBJECTIVES

We conducted a theoretical reappraisal of the FTLB literature to clarify the validity of the concept and its diagnostic implications.

METHODS

This paper addresses several key aspects of the current FTLB literature: circular reasoning, the complications of the FTLB phenomenology and demographics, the impact of FTLB on tic literature at large, and issues with alignment of the FTLB concept with the diagnostic criteria for functional disorders.

RESULTS

The clinical approach to FTLB might involve circular reasoning due to a lack of clinical benchmarks. The FTLB phenomenology and demographics may need more work to ensure a lack of bias and a proper description of this patient group including a clear distinction from tics. The impact of the FTLB discussion on the wider literature needs consideration. The validation of positive signs may help with both these endeavors and pave way to the inclusion of FTLB within psychiatric classification systems. Furthermore, the coexistence of FTLB and tics within the same patient needs to be addressed.

CONCLUSION

More research may be needed to fully establish the diagnosis of FTLB and differentiate it from tics.

Neural representations of statistical and rule-based predictions in Gilles de la Tourette syndrome

Gilles de la Tourette syndrome (GTS) is a disorder characterised by motor and vocal tics, which may represent habitual actions as a result of enhanced learning of associations between stimuli and responses (S-R). In this study, we investigated how adults with GTS and healthy controls (HC) learn two types of regularities in a sequence: statistics (non-adjacent probabilities) and rules (predefined order). Participants completed a visuomotor sequence learning task while EEG was recorded. To understand the neurophysiological underpinnings of these regularities in GTS, multivariate pattern analyses on the temporally decomposed EEG signal as well as sLORETA source localisation method were conducted. We found that people with GTS showed superior statistical learning but comparable rule-based learning compared to HC participants. Adults with GTS had different neural representations for both statistics and rules than HC adults; specifically, adults with GTS maintained the regularity representations longer and had more overlap between them than HCs. Moreover, over different time scales, distinct fronto-parietal structures contribute to statistical learning in the GTS and HC groups. We propose that hyper-learning in GTS is a consequence of the altered sensitivity to encode complex statistics, which might lead to habitual actions.

Increase in Functional Tic Presentations in Sexual Orientation and Gender Identity Minority Youth During Coronavirus Disease 2019

BACKGROUND

Functional tic disorders are among the least common functional movement disorders, but their prevalence rose during the coronavirus disease 2019 (COVID-19) pandemic. Although female adolescents develop functional neurological disorders at higher rates than males, investigations into sexual orientation and gender identity (SOGI) status of these patients are limited.

METHODS

We completed a retrospective, cross-sectional time series examining the incidence of new-onset functional tic disorders in youth presenting to the Massachusetts General Hospital Movement Disorder clinics before and during the COVID-19 pandemic. Data were collected by searching for relevant International Classification of Diseases (ICD)-10 diagnostic codes in youth aged nine to 26 years using a hospital-wide data repository. Individual cases were reviewed for inclusion based on clinical criteria and expert consensus.

RESULTS

The prevalence of functional tic presentations in youth rose 8.6-fold from pre- to postpandemic levels (Fisher exact test P < 0.001), whereas the prevalence of developmental tic presentations pre- and postpandemic remained stable (114 vs 112). SOGI minority youth comprised 37% of those with functional tics (total n = 19). Ninety five percent of patients with functional tics identified as female, with 10% of these identifying as transgender.

CONCLUSIONS

Our data confirm previously demonstrated dramatic rises in functional tic presentations during the COVID-19 pandemic and, more notably, reveal a strong association with SOGI minority status. We highlight the potential link between functional tic disorders and SOGI minority status. Providing a safe and supportive clinical environment and addressing stress linked to SOGI minority status may help to improve patient prognosis.

Functional Tic-like Behaviors: From the COVID-19 Pandemic to the Post-Pandemic Era

During the COVID-19 pandemic, there have been multiple reports about an unforeseen surge in adolescents and young adults exhibiting sudden onset functional tic-like behaviors. This phenomenon has been mainly associated with the female gender and occasionally after exposure to social media content featuring similar patterns of functional tic-like behaviors. A significant portion of these individuals have been directed to specialist clinics for movement disorders with initial misdiagnoses of late-onset refractory Tourette syndrome. Distinguishing between rapid onset functional tic-like behaviors and neurodevelopmental tics as part of Tourette syndrome can be challenging; however, the differential diagnosis is facilitated by focusing on specific clinical and demographic factors, which we have explored in a systematic literature review. Compared to neurodevelopmental tics, functional tic-like behaviors typically present with a more abrupt and intense manifestation of symptoms, onset at a later age, higher prevalence among females, inability to suppress tics, coexisting anxiety and depression, and sometimes a history of exposure to social media content portraying tic-like behaviors of a similar nature. This novel manifestation of a functional neurological disorder may thus be viewed as an emerging neuropsychiatric condition potentially triggered/exacerbated by the psychosocial repercussions of the COVID-19 crisis.

Recent advances in understanding the neurobiology of pediatric functional neurological disorder

INTRODUCTION

Functional neurological disorder (FND) is a neuropsychiatric disorder that manifests in a broad array of functional motor, sensory, or cognitive symptoms, which arise from complex interactions between brain, mind, body, and context. Children with FND make up 10%-20% of presentations to neurology services in children's hospitals and up to 20% of adolescents admitted to hospital for the management of intractable seizures.

AREAS COVERED

The current review focuses on the neurobiology of pediatric FND. The authors present an overview of the small but growing body of research pertaining to the biological, emotion-processing, cognitive, mental health, physical health, and social system levels.

EXPERT OPINION

Emerging research suggests that pediatric FND is underpinned by aberrant changes within and between neuron-glial (brain) networks, with a variety of factors - on multiple system levels - contributing to brain network changes. In pediatric practice, adverse childhood experiences (ACEs) are commonly reported, and activation or dysregulation of stress-system components is a frequent finding. Our growing understanding of the neurobiology of pediatric FND has yielded important flow-on effects for assessing and diagnosing FND, for developing targeted treatment interventions, and for improving the treatment outcomes of children and adolescents with FND.

Resting network architecture of theta oscillations reflects hyper-learning of sensorimotor information in Gilles de la Tourette syndrome

Gilles de la Tourette syndrome is a neurodevelopmental disorder characterized by motor and vocal tics. It is associated with enhanced processing of stimulus-response associations, including a higher propensity to learn probabilistic stimulus-response contingencies (i.e. statistical learning), the nature of which is still elusive. In this study, we investigated the hypothesis that resting-state theta network organization is a key for the understanding of superior statistical learning in these patients. We investigated the graph-theoretical network architecture of theta oscillations in adult patients with Gilles de la Tourette syndrome and healthy controls during a statistical learning task and in resting states both before and after learning. We found that patients with Gilles de la Tourette syndrome showed a higher statistical learning score than healthy controls, as well as a more optimal (small-world-like) theta network before the task. Thus, patients with Gilles de la Tourette syndrome had a superior facility to integrate and evaluate novel information as a trait-like characteristic. Additionally, the theta network architecture in Gilles de la Tourette syndrome adapted more to the statistical information during the task than in HC. We suggest that hyper-learning in patients with Gilles de la Tourette syndrome is likely a consequence of increased sensitivity to perceive and integrate sensorimotor information leveraged through theta oscillation-based resting-state dynamics. The study delineates the neural basis of a higher propensity in patients with Gilles de la Tourette syndrome to pick up statistical contingencies in their environment. Moreover, the study emphasizes pathophysiologically endowed abilities in patients with Gilles de la Tourette syndrome, which are often not taken into account in the perception of this common disorder but could play an important role in destigmatization.

Rethinking Movement Disorders

At present, clinical practice and research in movement disorders (MDs) focus on the "normalization" of altered movements. In this review, rather than concentrating on problems and burdens people with MDs undoubtedly have, we highlight their hidden potentials. Starting with current definitions of Parkinson's disease (PD), dystonia, chorea, and tics, we outline that solely conceiving these phenomena as signs of dysfunction falls short of their complex nature comprising both problems and potentials. Such potentials can be traced and understood in light of well-established cognitive neuroscience frameworks, particularly ideomotor principles, and their influential modern derivatives. Using these frameworks, the wealth of data on altered perception-action integration in the different MDs can be explained and systematized using the mechanism-oriented concept of perception-action binding. According to this concept, MDs can be understood as phenomena requiring and fostering flexible modifications of perception-action associations. Consequently, although conceived as being caught in a (trough) state of deficits, given their high flexibility, people with MDs also have high potential to switch to (adaptive) peak activity that can be conceptualized as hidden potentials. Currently, clinical practice and research in MDs are concerned with deficits and thus the "deep and wide troughs," whereas "scattered narrow peaks" reflecting hidden potentials are neglected. To better delineate and utilize the latter to alleviate the burden of affected people, and destigmatize their conditions, we suggest some measures, including computational modeling combined with neurophysiological methods and tailored treatment. © 2024 International Parkinson and Movement Disorder Society.

Premonitory Urge in Patients with Tics and Functional Tic-like Behaviors

BACKGROUND

Premonitory urges (PU) are well described in primary tics, but their frequency and intensity in functional tic-like behaviors (FTLB) are unclear.

OBJECTIVE

To study the experience of PU in patients with FTLB.

METHODS

We compared the results of the premonitory urge for tics scale (PUTS) in adults with tics and FTLB in the University of Calgary Adult Tic Registry.

RESULTS

We included 83 patients with tics and 40 with FTLB. When comparing patients with tics, FTLB with tics and FTLB only, we did not detect significant differences either in the total PUTS score (P = 0.39), or in any of the individual PUTS item sub-scores (P values ranging between 0.11 and 0.99).

CONCLUSIONS

Patients with FTLB report PU at similar frequency and intensity to patients with tics. This finding confirms that PU are not a useful feature to discriminate FTLB from tics.

Functional Tic-Like Behaviors: A Common Comorbidity in Patients with Tourette Syndrome

BACKGROUND

Comorbid functional tic-like behaviors (FTB) have been described only rarely in patients with Tourette syndrome (TS).

OBJECTIVES

We present the first large sample of patients suffering from TS and FTB to raise awareness of this clinical presentation and to guide how to differentiate one from the other.

METHODS

We analyzed clinical data of 71 patients (n = 27 [38.0%] female, mean age: 21.5, range: 11-55) with TS + FTB.

RESULTS

In the majority of patients, FTB started abruptly on average 15 years after tic onset with "treatment-resistant" complex movements and ("coprophenomena-like") vocalizations preceded by timely related psychological stressors. Psychological evaluation revealed evidence for internal conflicts (79%), emotional dysregulation (56%), and maintaining factors (70%). About one third of patients had a positive history for further medically unexplained symptoms. Compared to a large TS sample (n = 1032), patients with TS + FTB were more likely to be female, and presented significantly more common with "coprophenomena-like" symptoms, atypical influential factors, atypical descriptions of premonitory sensations, and higher rates of comorbid obsessive-compulsive disorder and "self-injurious" behavior.

CONCLUSIONS

Based on our data it can be assumed that FTB is a common comorbidity in TS, similar to functional overlay in other movement disorders and epilepsy. Before classifying a patient as suffering from treatment-resistant TS, FTB should be ruled out.

Social media and ADHD: implications for clinical assessment and treatment

The interaction between social media use and mental health is complicated. The mental health information shared on these platforms is frequently of poor quality but has the potential to exert powerful influence on users. Social media trend peaks in some mental disorders have led to increases in illness behaviour through social contagion. There has been a marked upsurge in online interest in attention deficit hyperactivity disorder (ADHD) over the last number of years, which has been particularly noticeable since the onset of the COVID-19 pandemic. The exponential increase in online ADHD interest has the potential to contribute to overloading mental health services with referrals. Mental health professionals and organisations need to consider strategies to ensure that quality health information is disseminated to younger audiences.

What distinguishes patients with mass social media-induced illness presenting with Tourette-like behavior from those with Tourette syndrome? Results of a prospective cohort study

Since 2019, a global increase in patients presenting with functional Tourette-like behaviors (FTB) has been observed. This has been related to the exposure of tic-related content in social media, although other factors seem to further fuel this phenomenon. Recently, we, therefore, proposed the term mass social media-induced illness (MSMI) as, in our opinion, this phenomenon constitutes a new type of mass sociogenic illness (MSI) that is in contrast to all recent outbreaks spread solely via social media. In accordance with this hypothesis, we were able to identify the host of the German YouTube channel "Gewitter im Kopf" ("Thunderstorm in the brain") as the initial virtual index case. The purpose of this paper is to present clinical characteristics of a sample of 32 patients diagnosed with MSMI-FTB compared to a large sample of patients with Tourette syndrome (TS) and other chronic tic disorders (CTD) (n = 1032) from the same center in Germany indicating clinical factors helpful to distinguish between tics in TS/CTD and MSMI-FTB. Our main findings were: in patients with MSMI-FTB compared to those with TS/CTD we found (i) a significantly higher age at onset, (ii) a significantly higher rate of females, (iii) a significantly higher rate of obscene and socially inappropriate symptoms, (iv) a significantly lower rate of comorbid ADHD, and (v) a significantly lower rate of OCD/OCB. In contrast, rates of comorbid anxiety and depression as well as reported frequencies of premonitory urges/sensations and suppressibility of symptoms did not differ between groups.

An investigation into mothers' experiences of their children's functional tic-like behaviour and tic attacks

OBJECTIVE

This is the first study to systematically explore the lived experiences of sudden and new onset of severe functional tics from the perspective of the mother's experiences and describes their attempts to access support services in the United Kingdom.

METHOD

Twenty-One mothers of young people aged between 12 to 17 years with functional tic-like behaviour (FTLB) took part in semi-structured interviews. Thematic analysis of the transcribed interviews revealed gaps and inconsistencies within the process of gaining access to professional services and a lack of support for the management of tics and functional tic-like movements, in addition to highlighting the impact it had on daily family life.

RESULTS

The themes generated included the occurrence and development of tics, the severity and intensity of symptoms, the psychological impact on the family and the need to make recommendations for a clear care pathway. Managing the impact of the FTLB and co-occurring conditions such as suicidal ideation and self-harm, as well as the physical and emotional trauma, commonly contributed to feelings of isolation and helplessness, which impacted negatively on the family's ability to function and participate in society.

CONCLUSIONS

The findings emphasize the urgent need to create a clear management pathway for those experiencing FTLB, including the need for more professionals with relevant knowledge, to improve the dialogue with families during the referral process, whilst prioritising the treatment of anxiety and other identified mental health concerns.

Integrated cognitive behavioral intervention for functional tics (I-CBiT): case reports and treatment formulation

Introduction

The onset of the COVID-19 pandemic saw a global surge in functional tic-like behaviors (FTLBs). FTLBs are unique from primary tic disorders. They are thought to manifest through a complex interplay between environmental and personal factors, including the stress-arousal system, and are characterized by their sudden and explosive onset. Accordingly, common interventions for tic disorders show limited efficacy in this population. We present an Integrated Cognitive Behavioral Intervention for Functional Tics (I-CBiT) that uses an urge acceptance model to manage tics and related stress and anxiety.

Methods

We describe the treatment outcomes of eight young people presenting with new and sudden onset FTLBs who underwent I-CBiT, which integrates traditional behavioral tic interventions with third-wave cognitive behavioral therapies. All cases completed the three-phase intervention involving core components of psychoeducation, exposure and response prevention with urge acceptance, sensory grounding strategies, and cognitive behavioral intervention targeting the stress-arousal system. Tic severity and impairment were assessed prior to treatment and at completion.

Results

All cases showed a significant reduction in tic severity post I-CBiT and an improvement in overall daily living function. These cases highlight the role of urge acceptance in managing both tic urges and the underlying stress-arousal system to bring about long-term change.

Conclusion

We demonstrated the efficacy of I-CBiT for managing FTLBs. Our findings illustrate the importance of treating underlying stress and anxiety in this population and, therefore, a need for greater interaction between multidisciplinary services in managing FTLBs to comprehensively cover the varied symptom presentations linked to thoughts, emotions, bodily sensations, and stress responses.

Illness-Promoting Psychological Processes in Children and Adolescents with Functional Neurological Disorder

Previous studies suggest that subjective distress in children with functional neurological disorder (FND) is associated with stress-system dysregulation and modulates aberrant changes in neural networks. The current study documents illness-promoting psychological processes in 76 children with FND (60 girls and 16 boys, aged 10.00-17.08 years) admitted to the Mind-Body Program. The children completed a comprehensive family assessment and self-report measures, and they worked with the clinical team to identify psychological processes during their inpatient admission. A total of 47 healthy controls (35 girls and 12 boys, aged 8.58-17.92 years) also completed self-report measures, but were not assessed for illness-promoting psychological processes. Children with FND (vs. controls) reported higher levels of subjective distress (total DASS score, t(104.24) = 12.18; p ˂ 0.001) and more adverse childhood experiences across their lifespans (total ELSQ score, t(88.57) = 9.38; p ˂ 0.001). Illness-promoting psychological processes were identified in all children with FND. Most common were the following: chronic worries about schoolwork, friendships, or parental wellbeing (n = 64; 84.2%); attention to symptoms (n = 61; 80.3%); feeling sad (n = 58; 76.3%); experiencing a low sense of control (helplessness) in relation to symptoms (n = 44; 57.9%); pushing difficult thoughts out of mind (n = 44; 57.9%); self-critical rumination (n = 42; 55.3%); negative/catastrophic-symptom expectations (n = 40; 52.6%); avoidance of activities (n = 38; 50%); intrusive thoughts/feelings/memories associated with adverse events (n = 38, 50%); and pushing difficult feelings out of mind (n = 37; 48.7%). In children with FND-disabled enough to be admitted for inpatient treatment-illness-promoting psychological processes are part of the clinical presentation. They contribute to the child's ongoing sense of subjective distress, and if not addressed can maintain the illness process. A range of clinical interventions used to address illness-promoting psychological processes are discussed, along with illustrative vignettes.

[Media's Stranglehold on Storm and Stress - The Sorrows of Generation Z about Sex and Gender]

Media's Stranglehold on Storm and Stress - The Sorrows of Generation Z about Sex and Gender Abstract: The feeling of not belonging to one's birth sex is not new; one can trace this phenomenon back even to ancient mythology. Although it has always been rare, there has recently been a sharp increase in gender identity deviations among adolescents. This text addresses this problem by asking to what extent this development also results from upheavals in the cultural landscape and, above all, in media technology. Do they cause young people to believe they are in the "wrong gender" and, in extreme cases, to strive for transition? We present the most salient cornerstones of the planned German self-determination law (Self-ID), most of which, however, are unlikely to do justice to the underlying problem. The text concludes by describing several unanswered questions concerning this matter and by attempting to propose first answers. The advantages of a gender-exploratory over the trans affirmative therapy approach are summarized.

Distinguishing functional from primary tics: a study of expert video assessments

BACKGROUND

Reliably applied criteria to differentiate functional from primary tics are lacking. In the absence of biological markers, the development of new diagnostic criteria to assist clinicians is predicated on expert judgement and consensus. This study examines the level of diagnostic agreement of experts in tic disorders using video footage and clinical descriptions.

METHODS

Using a two-part survey, eight experts in the diagnosis and management of tics were first asked to study 24 case videos of adults with primary tics, functional tics or both and to select a corresponding diagnosis. In the second part of the survey, additional clinical information was provided, and the diagnosis was then reconsidered. Inter-rater agreement was measured using Fleiss' kappa. In both study parts, the factors which influenced diagnostic decision-making and overall diagnostic confidence were reviewed.

RESULTS

Based on phenomenology alone, the diagnostic agreement among the expert raters was only fair for the pooled diagnoses (κ=0.21) as well as specifically for functional (κ=0.26) and primary tics (κ=0.24). Additional clinical information increased overall diagnostic agreement to moderate (κ=0.51) for both functional (κ=0.6) and primary tics (κ=0.57). The main factors informing diagnosis were tic semiology, age at tic onset, presence of premonitory urges, tic suppressibility, the temporal latency between tic onset and peak severity, precipitants and tic triggers and changes in the overall phenotypic presentation.

CONCLUSIONS

This study confirmed that in the absence of clinical information, the diagnostic distinction between primary and functional tics is often difficult, even for expert clinicians.

Neurodevelopmental versus functional tics: A controlled study

BACKGROUND

An unprecedented increase in newly developed functional tics, mainly in young females, has been reported during the COVID-19 pandemic. We set out to complement existing case series with the largest controlled study to date on the clinical phenomenology of functional tics versus neurodevelopmental tics.

METHODS

Data from 166 patients were collected at a specialist clinic for tic disorders during a three-year period overlapping with the COVID-19 pandemic (2020-2023). We compared the clinical features of patients who developed functional tics during the COVID-19 pandemic (N = 83) to patients with Tourette syndrome matched for age and gender (N = 83).

RESULTS

Female adolescents and young adults accounted for 86% of the clinical sample of patients with functional tics, who were less likely to report a family history of tic disorders than their matched controls with Tourette syndrome. Co-morbidity profiles were significantly different: anxiety and other functional neurological disorders were more strongly associated with functional tics, whereas attention-deficit and hyperactivity disorder and tic-related obsessive-compulsive behaviors co-occurred more frequently with neurodevelopmental tics. Overall, absence of tic-related obsessive-compulsive behaviors (t = 8.096; p < 0.001) and absence of a family history of tics (t = 5.111; p < 0.001) were the strongest predictors of the diagnosis of functional tics. Compared to neurodevelopmental tics, functional tics were more likely to present acutely/subacutely at a later age (21 versus 7 years), without a clear rostro-caudal progression. Coprophenomena, self-injurious behaviors, and complex clinical manifestations such as blocking tics, throwing tics, and tic attacks, were all over-represented in the functional group.

CONCLUSIONS

Our findings provide robust confirmation of both patient-related variables and tic characteristics contributing to the differential diagnosis between functional tics developed during the pandemic and neurodevelopmental tics reported by patients with Tourette syndrome.

Outcome in Pediatric Functional Tic Disorders Diagnosed During the COVID-19 Pandemic

OBJECTIVES

The incidence of pediatric functional tics has surged during the COVID-19 pandemic with little known about prognosis. To address this knowledge gap, the investigators examined clinical courses of functional tics diagnosed during the pandemic and explored factors predicting prognosis.

METHODS

Study personnel reviewed electronic medical records of 29 pediatric patients diagnosed as having functional tics between March 1, 2020, and December 31, 2021, and estimated Clinical Global Impression-Improvement (CGI-I) scores at follow-up encounters. Twenty patient-guardian dyads completed telephone interviews. Logistic regression models were used to identify possible predictors of clinical trajectories.

RESULTS

Of the 29 patients, 21 (82%) reported at least some improvement since diagnosis at the time of the last follow-up, with a median CGI-I score of 2 (much improved). During the telephone interview, 11 of 20 patients noted ongoing interference from tics, and 16 of 20 agreed with the diagnosis of functional tics. Median time from symptom onset to diagnosis was 197 days, with most patients reporting at least a mild reduction of symptoms (CGI-I score <4) at a median of 21 days after diagnosis. At a median follow-up time of 198 days after diagnosis, patients reported significant but not complete improvement. Greater age and longer time to diagnosis decreased odds of improvement within 1 month of diagnosis.

CONCLUSIONS

Most patients showed improvements in but not the resolution of functional tic symptoms after diagnosis. These data support the importance of early diagnosis for functional tics.

Clarifying the Differences between Patients with Organic Tics and Functional Tic-Like Behaviors

Due to the global increase in the number of patients with Functional Tic-Like Behaviors (FTLB), it has become increasingly important to find reliable differences between this patient group and patients with organic tics (OTs), which can be used in differential diagnosis. The purpose of this retrospective study was to critically examine both established and suggested differences between the patient groups. A total of 53 FTLB patients and 200 OT patients were included. Several findings from the current literature were replicated in this study: Compared to patients with OTs, patients with FTLB had significantly more complex tics, were older at symptom onset, were more likely to be female, and were less likely to have family members with tics. Furthermore, the study also revealed new differences between the groups: Patients with FTLB had significantly more family members with a psychiatric disorder, were more likely to have experienced an adverse psychosocial event immediately before symptom onset, and had significantly fewer simple tics. Finally, this study was unable to replicate the previously found differences in comorbidities between patients with OTs and FTLB. These findings could contribute significantly to the understanding of FTLB's etiology and to improve diagnosis, as including the presence of simple tics and comorbidities in the diagnostic criteria might be discussed in future studies.

Have We Forgotten What Tics Are? A Re-Exploration of Tic Phenomenology in Youth with Primary Tics

Background

The first systematic description of tics in a large sample was in 1978.

Objectives

To assess the phenomenology of tics in youth and investigate how age and sex influence tic phenomenology.

Methods

Children and adolescents with primary tic disorders have been prospectively included in our Registry in Calgary, Canada, since 2017. We examined tic frequency and distribution using the Yale Global Tic Severity Scale, differences between sexes, and changes in tic severity with age and with mental health comorbidities.

Results

A total of 203 children and adolescents with primary tic disorders were included (76.4% males; mean age = 10.7 years, 95% CI = 10.3-11.1). At first assessment, the most common simple motor tics were eye blinking (57%), head jerks/movements (51%), eye movements (48%) and mouth movements (46%); 86% had at least one simple facial tic. The most frequent complex motor tics were tic-related compulsive behaviors (19%). Throat clearing was the most common simple phonic tic (42%); 5% only had coprolalia. Females had higher frequency and intensity of motor tics than males (P = 0.032 and P = 0.006, respectively), associated with greater tic-related impairment (P = 0.045). Age was positively correlated with the Total Tic Severity Score (coefficient 0.54, P = 0.005), along with the number, frequency and intensity of motor tics but not with their complexity. Psychiatric comorbidities were associated with greater tic severity.

Conclusions

Our study suggests that age and sex affect clinical presentation in youth with tics. The phenomenology of tics in our sample was similar to the 1978 description of tics, and contrasts with functional tic-like behaviors.

Functional tic-like presentations differ strikingly from Provisional Tic Disorder

Background: Recent years have seen a dramatic increase in new "tic" cases in teens and young adults. These individuals often present with fulminant onset of symptoms not commonly seen in Tourette syndrome (TS) and are often diagnosed with Functional Neurological Symptom Disorder (FND-tic). However, some authors have questioned whether this illness truly differs from typical Provisional Tic Disorder (PTD) and TS. Previous studies have compared FND-tic, usually a few months after symptom onset, to patients with TS, usually years after symptom onset. We sought to test whether the presenting symptoms of FND-tic differ substantially from those in patients at a similar duration of symptoms who are later diagnosed with TS. Methods: This comparative study examines clinical features summarized from published reports of FND-tic with novel data from a longitudinal study of PTD. This study came from a referral center for TS and tic disorders and included 89 children with tics whose first tic occurred a median of 3.6 months earlier, nearly all of whom were diagnosed with a chronic tic disorder at follow-up. Specifically, we examine clinical features identified in a recent literature review as supporting a diagnosis of FND-tic, including symptom characteristics, course, severity and comorbidity. Results: Several clinical features dramatically distinguish the patients diagnosed with FND-tic from those diagnosed with typical PTD. For example, coprophenomena are reported at or shortly after symptom onset in over half of FND-tic patients, whereas even several months after onset, coprophenomena had occurred in only 1 of 89 children with PTD. Six clinical features each have a positive predictive value over 90% for FND-tic diagnosis if prior probability is 50%. Conclusions: These new data provide strong evidence supporting the diagnostic validity of FND-tic as distinct from TS.

Increased Number of Functional Tics Seen in Danish Adolescents during the COVID-19 Pandemic

BACKGROUND

 Global increase in functional tics in adolescents has been observed. Differentiating functional from classic tics is important since pathophysiology and treatment differ. We investigated possible triggers for development of functional tics and discuss the possible role of the coronavirus disease 2019 (COVID-19) pandemic and social media exposure in cases of functional tics seen during this period. Moreover, the treatment, and its efficacy is discussed.

METHODS

 Medical records of 28 Danish adolescents diagnosed with functional tics at the National Tourette Clinic, Department of Pediatrics, Herlev University Hospital, Denmark, from May 2020 to June 2021 have been retrospectively reviewed. Descriptive statistical analyses were used to analyze the data.

MAIN FINDINGS

 A total of 28 patients diagnosed with functional tics were included, 96.4% girls and 3.6% boys, mean age 14.4 years. Tic phenomenology differed from classic tics with more complex tics and no rostrocaudal progression. Note that 69.2% reported harmful tics. Also, 78.6% had trauma/precipitating event and 40% denounced lockdown related to the COVID-19 pandemic as trigger, both prior to onset of functional tics. Note that 60.7% reported psychiatric symptoms/diagnoses, 42.9% had a first-degree family member with psychiatric symptoms/diagnoses, and 96.4% were exposed to tics on social media prior to onset. Treatment consisted of psychoeducation, elements from cognitive behavioral therapy, and focus on psychiatric symptoms. All patients responded to the treatment.

CONCLUSION

 The vulnerability of the adolescents is characteristic. Treatment strategy has shown immediate positive effect. Consequences of the COVID-19 pandemic in combination with exposure to tics on social media could be part of the cause for the increase in number of functional tics.

European Society for the Study of Tourette Syndrome 2022 criteria for clinical diagnosis of functional tic-like behaviours: International consensus from experts in tic disorders

BACKGROUND AND PURPOSE

In 2020, health professionals witnessed a dramatic increase in referrals of young people with rapid onset of severe tic-like behaviours. We assembled a working group to develop criteria for the clinical diagnosis of functional tic-like behaviours (FTLBs) to help neurologists, pediatricians, psychiatrists, and psychologists recognize and diagnose this condition.

METHODS

We used a formal consensus development process, using a multiround, web-based Delphi survey. The survey was based on an in-person discussion at the European Society for the Study of Tourette Syndrome (ESSTS) meeting in Lausanne in June 2022. Members of an invited group with extensive clinical experience working with patients with Tourette syndrome and FTLBs discussed potential clinical criteria for diagnosis of FTLBs. An initial set of criteria were developed based on common clinical experiences and review of the literature on FTLBs and revised through iterative discussions, resulting in the survey items for voting.

RESULTS

In total, 24 members of the working group were invited to participate in the Delphi process. We propose that there are three major criteria and two minor criteria to support the clinical diagnosis of FTLBs. A clinically definite diagnosis of FTLBs can be confirmed by the presence of all three major criteria. A clinically probable diagnosis of FTLBs can be confirmed by the presence of two major criteria and one minor criterion.

CONCLUSIONS

Distinguishing FTLBs from primary tics is important due to the distinct treatment paths required for these two conditions. A limitation of the ESSTS 2022 criteria is that they lack prospective testing of their sensitivity and specificity.

Fitting in an Unfit Society With Autism Spectrum Disorder: Case Report

Evaluating behavioral mimicking is important in healthcare providers' everyday functioning with an increased presentation of Tourette syndrome-like cases during the COVID-19 pandemic, seen due to the popular video creators on social media (e.g., TikTok) exhibiting these behaviors. Individuals with autism spectrum disorder (ASD) face difficulties with connection and assimilation, and they adapt by camouflaging their behaviors to fit with those of the neurotypical majority. Our team evaluated the behaviors of one individual with ASD to establish whether camouflaging was playing a role in her psychiatric stabilization in our inpatient psychiatric unit. We present a case of a 30-year-old female with ASD, admitted to our long-term inpatient psychiatric facility for significant mood dysregulation that persisted despite numerous treatment approaches (mediations, groups, etc.). While her initial behaviors included head banging and self-induced falls, her behaviors seemed to change based on those of her peers, in an apparent attempt to camouflage into the social environment within the unit. She also appeared to learn new self-harm behaviors, such as skin picking, from peers around her. The team was able to establish a temporal link between some instances of peers exhibiting specific behaviors and our patient engaging in similar behavior. Although inpatient units effectively manage long-term stabilization in other psychiatric disorders, these environments are not designed for individuals with ASD. Treatment teams should recognize the malleability of behaviors in patients with ASD and must identify and manage behavioral mimicking early during inpatient psychiatric treatment; otherwise, it may lead to significant harm.

Impact of the COVID-19 pandemic on incidence of tics in children and young people: a population-based cohort study

BACKGROUND

Since the onset of the coronavirus (COVID-19) pandemic, clinicians have reported an increase in presentations of sudden and new onset tics particularly affecting teenage girls. This population-based study aimed to describe and compare the incidence of tics in children and young people in primary care before and during the COVID-19 pandemic in England.

METHODS

We used information from the UK Clinical Practice Research Datalink (CPRD) Aurum dataset and included males and females aged 4-11 years and 12-18 years between Jan 1, 2015, and Dec 31, 2021. We grouped the pre-pandemic period (2015-2019) and presented the pandemic years (2020, 2021) separately. We described the characteristics of children and young people with a first record of a motor or vocal tic in each time period. Incidence rates of tics by age-sex groups in 2015-2019, 2020, and 2021 were calculated. Negative binomial regression models were used to calculate incidence rate ratios.

FINDINGS

We included 3,867,709 males and females aged 4-18 years. Over 14,734,062 person-years of follow-up, 11,245 people had a first tic record during the whole study period. The characteristics of people with tics differed over time, with the proportion of females aged 12-18 years and the proportion with mental health conditions including anxiety increasing during the pandemic. Tic incidence rates per 10,000 person-years were highest for 4-11-year-old males in all three time periods (13.4 [95% confidence interval 13.0-13.8] in 2015-2019; 13.2 [12.3-14.1] in 2020; 15.1 [14.1-16.1] in 2021) but increased markedly during the pandemic in 12-18-year-old females, from 2.5 (2.3-2.7) in 2015-2019, to 10.3 (9.5-11.3) in 2020 and 13.1 (12.1-14.1) in 2021. There were smaller increases in incidence rates in 12-18-year-old males (4.6 [4.4-4.9] in 2015-2019; 4.7 [4.1-5.3] in 2020; 6.2 [5.5-6.9] in 2021) and 4-11-year-old females (4.9 [4.7-5.2] in 2015-2019; 5.7 [5.1-6.4] in 2020; 7.6 [6.9-8.3] in 2021). Incidence rate ratios comparing 2020 and 2021 with 2015-2019 were highest in the 12-18-year-old female subgroup (4.2 [3.6-4.8] in 2020; 5.3 [4.7-6.0] in 2021).

INTERPRETATION

The incidence of tics in children and young people increased across all age and sex groups during the COVID-19 pandemic, with a differentially large effect in teenage girls (a greater than four-fold increase). Furthermore, in those with tic symptoms, proportions with mental health disorders including anxiety increased during the pandemic. Further research is required on the social and contextual factors underpinning this rise in onset of tics in teenage girls.

FUNDING

National Institute for Health Research Nottingham Biomedical Research Centre.

Social media as an incubator of personality and behavioral psychopathology: Symptom and disorder authenticity or psychosomatic social contagion?

There has been an increasing recognition among both medical and psychological professionals, as well as the public media, of a concerning trend for child and adolescent users of audiovisual-based, algorithmic social media platforms (e.g., TikTok) to present with or claim functional psychiatric impairment that is inconsistent with or distinct from classic psychiatric nosology. In this short communication, we provide a detailed historical overview of this transdiagnostic phenomenon and suggest a conceptual model to organize thinking and research examining it. We then discuss the implications of our suggested model for accurate assessment, diagnosis, and medical-psychiatric treatment. We believe there is an urgent need for focused empirical research investigation into this concerning phenomenon that is related to the broader research and discourse examining social media influences on mental health.

Tourette syndrome: clinical features, pathophysiology, and treatment

Tourette syndrome is a chronic neurodevelopmental disorder characterised by motor and phonic tics that can substantially diminish the quality of life of affected individuals. Evaluating and treating Tourette syndrome is complex, in part due to the heterogeneity of symptoms and comorbidities between individuals. The underlying pathophysiology of Tourette syndrome is not fully understood, but recent research in the past 5 years has brought new insights into the genetic variations and the alterations in neurophysiology and brain networks contributing to its pathogenesis. Treatment options for Tourette syndrome are expanding with novel pharmacological therapies and increased use of deep brain stimulation for patients with symptoms that are refractory to pharmacological or behavioural treatments. Potential predictors of patient responses to therapies for Tourette syndrome, such as specific networks modulated during deep brain stimulation, can guide clinical decisions. Multicentre data sharing initiatives have enabled several advances in our understanding of the genetics and pathophysiology of Tourette syndrome and will be crucial for future large-scale research and in refining effective treatments.

The spectrum of functional tic-like behaviours: Data from an international registry

BACKGROUND AND PURPOSE

Between 2019 and 2022, there was a marked rise in adolescents/young adults seeking urgent help for functional tic-like behaviours (FTLBs). Given the global scale of this phenomenon, we aimed to pool cases from different institutions in an international registry to better characterize this spectrum and facilitate future longitudinal observation.

METHODS

An international collaborative group from 10 tertiary referral centres for tic disorders collected retrospective data on FTLB patients who sought specialists' attention between the last quarter of 2019 and June 2022. An audit procedure was used for collection of data, which comprised demographics, course of presentation and duration, precipitating and predisposing factors, phenomenology, comorbidities, and pharmacological treatment outcome.

RESULTS

During the study period, we collected data on 294 patients with FTLBs, 97% of whom were adolescents and young adults and 87% of whom were female. FTLBs were found to have a peak of severity within 1 month in 70% of patients, with spontaneous remissions in 20%, and a very high frequency of complex movements (85%) and vocalizations (81%). Less than one-fifth of patients had pre-existing primary tic disorder, 66% had comorbid anxiety disorders, 28% comorbid depressive disorders, 24% autism spectrum disorder and 23% attention deficit/hyperactivity disorder. Almost 60% explicitly reported exposure to tic-related social media content. The vast majority of pharmacologically treated patients did not report benefit with tic-suppressing medications.

CONCLUSIONS

Our data from the largest multicentre registry of FTLBs to date confirm substantial clinical differences from primary tic disorders. Social modelling was the most relevant contributing factor during the pandemic. Future longitudinal analyses from this database may help understand treatment approaches and responsiveness.

Rapid onset of functional tic-like behaviors among adolescent girls-Minnesota, September-November 2021

Background

On October 15, 2021, the Minnesota Department of Health began investigating a school cluster of students experiencing tic-like behaviors thought to be related to recent COVID-19. The objective of this report is to describe the investigation, key findings, and public health recommendations.

Methods

Affected students and proxies were interviewed with a standardized questionnaire including validated depression and anxiety screens.

Results

Eight students had tic-like behaviors lasting >24 h after initial report with onset during September 26-October 30, 2021. All eight students were females aged 15-17 years. All students either had a history of depression or anxiety or scored as having more than minimal anxiety or depression on validated screens. Four students previously had confirmed COVID-19: the interval between prior COVID-19 and tic symptom onset varied from more than a year prior to tic symptom onset to at the time of tic symptom onset.

Conclusion

The onset of tic-like behaviors at one school in Minnesota appeared to be related more to underlying mental health conditions than recent COVID-19. These findings highlight the need to better understand functional tic-like behaviors and adolescent mental health.

Burden of Neurological Diseases in the Philippines as Revealed by Web Searches: An Infodemiological Study

Due to the real-time acquisition of big data from the Internet, analysis of Google queries is now recognized as a valuable tool to explore and predict human behavior and interests. It was suggested that online data can be correlated with actual health data. Although the data are not structured nor systematic, the huge data from search engines can easily identify trends concerning diseases and other health concepts from a population perspective. Moreover, Internet data with the use of web search advertising nowadays may not only reveal the interest of the general population but also of the healthcare industry as reflected by the bid prices in search terms for medications. We aimed to compare the interests of the general population using monthly search volumes from Google and the healthcare industry using bid prices in web searches. Data used in this study were obtained from the Google Ads Application Programming Interface (API). This study evaluated the population's interest in neurological disorders by using search volumes related to neurology, either disease diagnosis or medications. Bid values generated in API were used as a proxy for the interests of the healthcare industry. Spearman's rank-order correlation was performed between search volumes and bid prices to determine significance. Among the neurologic diseases listed, the most searched were attention deficit hyperactivity disorder, migraine, and Alzheimer's disease. The most commonly searched drugs were oral antihypertensives (amlodipine, losartan, carvedilol), lipid-lowering agents (atorvastatin, simvastatin, rosuvastatin), and antiplatelets (acetylsalicylic acid, clopidogrel). The other most searched drugs were analgesics such as acetaminophen, tramadol, diclofenac, and morphine. The correlational analysis did not reveal a statistically significant correlation between search volume and bid price for both neurologic diseases and medications. Web searches may reflect the interest of the general population and the healthcare industry. However, there was disagreement in the search interests of the general population and the scientific community, including the pharmaceutical industry. Further studies are necessary in order to align these interests for the common benefit of all stakeholders.

TikTok Tourette's: Are We Witnessing a Rise in Functional Tic-Like Behavior Driven by Adolescent Social Media Use?

Perceptions of Tourette syndrome (TS) and tic disorders are often driven by social media. During the COVID-19 pandemic, social media consumption greatly increased, particularly in the adolescent population. In parallel with increased social media consumption, there has also been an increase in tic severity and functional tic-like behavior (FTLB). Given that many of the tic videos posted on social media are misleading, perpetuate false beliefs about TS, or reinforce tic-like behaviors, there is increasing concern that these videos are driving the rapid increase in FTLBs. Several studies have reviewed newly presenting cases of FTLB and have found shared characteristics, including that a higher proportion of affected individuals are female, there is a low proportion with a history of childhood or family tics, and symptom onset is typically acute and develops in the teenage years. In addition, the quality of the tics seen in association with FTLB mirrors many of the tics seen on popular social media channels, with higher rates of coprophenomena, tic attacks, and involvement of the trunk and extremities than is seen with typical tics. FTLBs are likely a specific subgroup of functional tics largely influenced by the portrayal of and growing popularity of functional tics posted on social media during the COVID-19 pandemic. However, several factors, including increased anxiety, social isolation, and social media use in general during the pandemic are likely also contributing factors to the surge of FTLBs seen recently. In this era of increased social media consumption, it will become increasingly important for clinicians to educate patients about where and how medical information is spread, to ensure the best possible diagnosis, treatment, and outcomes for patients.

Tourette syndrome research highlights from 2021

We summarize selected research reports from 2021 relevant to Tourette syndrome that the authors consider most important or interesting. The authors welcome article suggestions and thoughtful feedback from readers.

Diagnosis and Management of Functional Tic-Like Phenomena

Over the past 3 years, a global phenomenon has emerged characterized by the sudden onset and frequently rapid escalation of tics and tic-like movements and phonations. These symptoms have occurred not only in youth known to have tics or Tourette syndrome (TS), but also, and more notably, in youth with no prior history of tics. The Tourette Association of America (TAA) convened an international, multidisciplinary working group to better understand this apparent presentation of functional neurological disorder (FND) and its relationship to TS. Here, we review and summarize the literature relevant to distinguish the two, with recommendations to clinicians for diagnosis and management. Finally, we highlight areas for future emphasis and research.

Why Tic Severity Changes from Then to Now and from Here to There

Much of the research regarding Tourette's syndrome (TS) has focused on why certain individuals develop tics while others do not. However, a separate line of research focuses on the momentary influences that cause tics to increase or decrease in patients who are already known to have TS or another chronic tic disorder (CTD). Environmental and internal variables such as fatigue, anxiety, and certain types of thoughts all have been shown to worsen tic severity and may even overcome the positive effects of treatment. Other influences such as stress, distraction, and being observed have had mixed effects in the various studies that have examined them. Still, other variables such as social media exposure and dietary habits have received only minimal research attention and would benefit from additional study. Understanding the impact of these environmental and internal influences provides an opportunity to improve behavioral treatments for TS/CTD and to improve the lives of those living with these conditions. This review will examine the current literature on how these moment-to-moment influences impact tic expression in those with TS/CTD.

Functional tics, the pandemic and social media

Functional tics form a part, albeit a small proportion, of the wider spectrum of functional neurological disorders (FND). In this review, we focus on the recent increase in presentations of functional tics since the COVID-19 pandemic. A functional tic disorder is often characterised by rapid onset of complex motor and vocal tics predominantly in adolescent females, distinct from Tourette’s syndrome which typically begins in younger boys. Rapid onset of severe tics merging into other types of functional neurological disorders, marked coprolalia, self-injury from tics and school absenteeism, are additional features of functional tics, however, the disorders can co-exist. There has been a lot of focus on social media as an explanation for the rise in cases, although the data suggest that this is just one of many potential factors, with the pandemic itself and its effect on teenage lives being the most likely culprit.

The recent surge of functional movement disorders: social distress or greater awareness?

PURPOSE OF REVIEW

To analyze the interrelated factors that have led to the striking increase in functional movement disorders in recent years, with a focus on functional tic-like behaviours (FTLB).

RECENT FINDINGS

The sudden onset of FTLB has been widely observed in several countries since the beginning of the SARS-CoV-2 pandemic, whereas it was previously very rarely reported. Pandemic-related FTLB typically occur in young females, share complex, disabling and tic-lookalike patterns, and are usually triggered by the exposure to videos portraying tic-like behaviours on social media. Both pandemic-related FTLB and prepandemic FTLB are associated with high levels of depression and anxiety. FTLB related to the pandemic highlight the role of social media in the psychopathological behaviours of our time.

SUMMARY

We suggest FTLB are due to a combination of predisposing factors (high genetic and epigenetic risk for anxiety and depression, negative past experiences) and precipitating factors (pandemic and its impact on mental health, exposure to certain social media content). These factors of vulnerability may increase the risk of developing behavioural and emotional problems in youth, such as FTLB. Early diagnosis and appropriate treatment of psychiatric comorbidities seem to be predictors of positive prognosis.

The Phenomenology of Tics and Tic-Like Behavior in TikTok

BACKGROUND

Pediatricians and pediatric subspecialists worldwide have reported a marked increase in functional (conversion) disorders with tic-like behaviors during the COVID-19 pandemic. These patients often report frequent viewing of Tourette syndrome (TS) TikTok videos, suggesting disease modeling. We aimed to evaluate tic phenomenology in videos posted on TikTok.

METHODS

The 100 most-viewed videos under #tourettes in TikTok were randomly assigned to two of three primary reviewers (<2 years independent practice), all pediatric neurologists specializing in movement disorders, for extraction and classification of tic phenomenology. Initial disagreements were solved by consensus. If not resolved, one of five senior reviewers (>2 years independent pediatric movement disorder practice) served as a tiebreaker. In addition, two primary and one senior reviewer rated each video on a Likert scale from 1 = "All the tics are typical of TS" to 5 = "None of the tics are typical of TS". Median scores and Spearman correlation between primary and senior reviewers were calculated.

RESULTS

Six videos without tic-like behaviors were excluded. Most videos depicted coprophenomena (coprolalia: 53.2%; copropraxia: 20.2%), often with unusual characteristics. Frequently, videos demonstrated atypical phenomenology such as very strong influence by the environment (motor: 54.3%; phonic: 54.3%), aggression (19.1%), throwing objects (22.3%), self-injurious behaviors (27.7%), and long phrases (>3 words; 45.7%). Most videos portrayed atypical, nontic behaviors (median [IQR] Likert ratings: 5 [4-5]). Primary vs. senior rater scores demonstrated moderate agreement (r = 0.46; P < 0.001).

CONCLUSIONS

TS symptom portrayals on highly viewed TikTok videos are predominantly not representative or typical of TS.

Functional tic-like behaviours during the COVID-19 pandemic: Follow-up over 12 months

BACKGROUND

Functional tics are included in the wide spectrum of functional movement disorders (FMDs). Their distinction from organic tics is challenging because they both phenomenologically present common features. During the COVID-19 pandemic, there has been an increase in functional tic-like behaviours in vulnerable children and adolescents after social media exposure. This study explores the phenomenology and course of a cohort of newly diagnosed functional tic-like behaviors.

METHODS

We analysed clinical data of 243 patients affected by tic disorders collected at outpatient Tourette Clinic, Child and Adolescent Neurology and Psychiatry Unit, Catania University. Among the clinical cohort with functional tic-like behaviors, we evaluated the clinical course of symptoms at follow-up visits after 6 and 12 months.

RESULTS

Among the cohort of 243 patients referred for evaluation at our centre, 11 were diagnosed with functional tic-like behaviours. The majority of participants with functional tic-like behaviours were female with a mean age of 15 years old and presented an explosive symptom's onset. At follow-up visit after 12 months, patients with functional tic-like behaviors showed a significant variation in the severity of tics and anxiety symptoms. Conversely, depressive, and obsessive-compulsive symptoms did not significantly differ during the follow-up.

CONCLUSION

Our data suggest that several characteristics in clinical course and their phenomenology can help clinicians to distinguish functional tic-like behaviours from organic tics. Our results also suggest a better outcome for tics and anxiety symptoms respect on other comorbidities. A prompt diagnosis and management not only of tics but also comorbidities are recommended, as generally conventional pharmacotherapy for tics does not have positive effects on these patients.

A Randomized Controlled Trial Comparing Videoconference vs. Face-to-Face Delivery of Behavior Therapy for Youths With Tourette Syndrome in the Time of COVID-19

OBJECTIVE

To evaluate the clinical effectiveness of online remote behavior therapy, compared with face-to-face therapy in reducing tics and co-occurring disorders associated with the tics in a sample of youths with Tourette Syndrome.

DESIGN

A randomized controlled trial. TS patients were randomized to receive face-to-face or online remote behavior therapy.

PARTICIPANTS

40 children aged between 9 and 16 years affected by Tourette Syndrome.

RESULTS

Online remote and face-to-face behavior therapy are equally effective in the treatment of tics and co-occurring disorders in children and adolescents affected by Tourette Syndrome. Both groups showed an improvement in the severity of tics, obsessive-compulsive symptoms, and anxiety symptoms, as assessed by neuropsychological findings. Online remote behavior therapy was more effective for reducing depressive symptoms than face-to-face behavior therapy.

CONCLUSIONS

Online remote behavior therapy is a promising tool for behavioral therapies for patients with Tourette Syndrome and may represents an alternative treatment option.

The Rise of Functional Tic-Like Behaviors: What Do the COVID-19 Pandemic and Social Media Have to Do With It? A Narrative Review

BACKGROUND

There has been a rise in explosive onset of tic-like behaviors during the COVID-19 pandemic. Historically, this is an uncommon phenomenology of functional movement disorders across all ages. Both the psychological burden of the pandemic and social media usage have been implicated in the rise of these tic-like behaviors.

METHODS

This paper provides a narrative review of the literature on chronic tic disorders, functional tics, and mass functional illness with particular focus on the key distinguishing features, role of social media, and the role of COVID-19.

RESULTS

The COVID-19 pandemic has profoundly affected the mental health of many individuals, including children, adolescents, and their caregivers. Implementation of lockdowns, lifestyle disruptions, school closures, and social distancing have driven a surge in social media and digital technology use. The combination of predisposing factors, the psychological burden of the COVID-19 pandemic, and social media are implicated in the rise and spread of tic-like behaviors; which may represent a modern-day form of mass functional illness. While many of the features overlap with functional tics, there are emerging distinctive features that are important to recognize. A more encompassing term, Functional Tic-Like Behaviors, is used to better reflect multiple contributing factors.

CONCLUSION

Knowledge of these differences is essential to mitigate downstream health effects and poor outcomes.