European clinical guidelines for Tourette syndrome and other tic disorders. Part III: behavioural and psychosocial interventions

A systematic review exploring perceptions of Tourette syndrome and tic disorders using the common-sense model of illness representations

OBJECTIVE

Tic disorders (TDs) are neurodevelopmental conditions characterised by tics and typically appear during childhood. The Common Sense Model of Self-Regulation (CSM) provides a useful theoretical framework for understanding health beliefs in people with TDs - and parents' beliefs given 'shared' illness experiences between child and parent. Exploring health beliefs in adults can also provide insight as to how TD-related beliefs may evolve over time. This systematic review aimed to use the CSM to synthesise findings from published studies exploring illness perceptions in people with TDs and parents.

METHODS

Six databases were searched for studies reporting findings assessing perceptions and beliefs of TDs that aligned with ≥1 CSM illness representation dimension. Forty-four studies were eligible and narratively synthesised.

RESULTS

The evidence particularly highlights the negative consequences of TDs upon employment opportunities, schooling and education, social lives and relationships - with experiences of stigma and discrimination weaving throughout these consequences. Findings from several studies reflecting emotional responses report feelings of self-consciousness, abnormality, and anxiety arising from TDs.

CONCLUSION

Findings have identified potential implications for research and practice, including identifying TD-related knowledge and beliefs that could be addressed through psychoeducation, and physiological and psychological outcomes which could be addressed through appropriate interventions.

PROTOCOL REGISTRATION

PROSPERO CRD42023446800.

Description, Implementation, and Efficacy of the Comprehensive Behavioral Intervention for Tics as First-Line Treatment for Tourette and Other Tic Disorders

Objective: To provide an evidence-based review of the Comprehensive Behavioral Intervention for Tic (CBIT) disorders. Results: For close to a century, behavioral interventions for managing tics associated with Tourette and other tic disorders (TDs) were incorrectly considered ineffective and dangerous by the professional community, due, in large part, to unfounded fears that efforts to suppress tics would lead to a host of negative psychological, and even physical, outcomes (e.g., symptom substitution, tic rebound). Spurred by a growing body of research to the contrary, the Comprehensive Behavioral Treatment for Tics (CBIT) was developed to provide a tolerable and effective nonpharmacological treatment option, alone or in combination with medication, for youth and adults with tics associated with Tourette or other TDs. CBIT combines two evidence-based practices, habit reversal training (HRT) to address the urge-tic relationship and a functional intervention to identify and neutralize tic-related environmental factors. Based on positive findings from two large-scale randomized controlled trials that involved a total of 248 8-69-year olds with Tourette or chronic TD, CBIT has been designated as a first-line treatment, when available, for treating tics by the American Academy of Neurology and the European and Canadian medical academies. Conclusions: CBIT has demonstrated acute and durable efficacy when delivered alone or in combination with medication, in person, or via telehealth, and in the presence or absence of common comorbid conditions. Additional research is needed to develop and test treatment guidelines for the use of CBIT in combination with pharmacologic, neuromodulatory, and other intervention modalities.

Exploring acupuncture as a therapeutic approach for tic disorders: a review of current understanding and potential benefits

Tic disorders (TD) refer to a condition where individuals experience recurring motor movements (e.g., eye blinking) and/or vocalizations (e.g., throat clearing). These disorders vary in terms of duration, cause, and manifestation of symptoms. Tourette's syndrome (TS) involves the presence of ongoing motor and vocal tics for a minimum of 1 year, with fluctuating intensity. Persistent chronic motor or vocal tic disorder is characterized by either motor or vocal tics (not both) present for at least 1 year. Provisional TD presents with either motor or vocal tics (not both) that have been present for less than 12 months. Though medications like Aripiprazole and dopamine receptor blockers are frequently prescribed, their potential unwanted consequences increase, may result in low adherence. In an effort to improve and broaden the care available for children diagnosed with TD, alternative methods such as acupuncture are being investigated and considered. Acupuncture is a method of traditional Chinese medicine that includes the placement of thin needles into particular areas of the body in order to correct any disruptions or irregularities. Research has demonstrated that acupuncture can help regulate abnormal brain function and relieve tic symptoms in individuals with TD. Additional studies are required to fully evaluate the usefulness of complementary treatments in addressing TD in young individuals, despite its common usage. Herein, we summarized the therapeutic effects of acupuncture in the treatment of TD.

Exposure and response prevention versus risperidone for the treatment of tic disorders: a randomized controlled trial

Introduction

The aim of this study was to directly compare behavior therapy (exposure & response prevention; ERP) with pharmacotherapy (risperidone) with respect to tic severity and quality of life in patients with Tourette's disorder or tic disorders.

Method

A total of 30 participants were randomly assigned to either ERP (12 weekly 1-hour sessions) or risperidone (flexible dosage of 1-6 mg) with follow-up at 3 and 9 months after end of treatment. Outcome measures included tic severity as measured by the Yale Global Tic Severity Scale, quality of life and side effects. Predefined informative hypotheses were evaluated using Bayes factors (BF), a Bayesian alternative for null hypothesis testing with p-values, that provides a more reliable and powerful method in the case of small samples. A BF larger than one indicates support for the informative hypothesis and the larger the BF, the stronger the support, with a BF between 3 and 10 being considered to provide moderate evidence.

Results

Both ERP and Risperidone were found to be effective with respect to tic severity at end of treatment (BF 5.35). At 9 months follow-up, results remained stable (BF 4.59), with an advantage of ERP over Risperidone at 3 months follow-up (BF 3.92). With respect to quality of life, an effect was found for ERP (BF 3.70 at 3 months follow up; BF 3.08 at 9 months follow-up). Dropout rates were higher in the medication condition, mainly due to significantly more side effects halfway during treatment, fading out towards end of treatment.

Discussion

Behavior therapy and medication are equally viable options in the treatment of tic disorders, with a slight preference for ERP based on follow-up results on tic severity and quality of life, and side effects.

Clinical trial registration

https://onderzoekmetmensen.nl/nl/node/23410/pdf, identifier NL-OMON23410.

When the interoceptive and conceptual clash: The case of oppositional phenomenal self-modelling in Tourette syndrome

Tourette syndrome (TS) has been associated with a rich set of symptoms that are said to be uncomfortable, unwilled, and effortful to manage. Furthermore, tics, the canonical characteristic of TS, are multifaceted, and their onset and maintenance is complex. A formal account that integrates these features of TS symptomatology within a plausible theoretical framework is currently absent from the field. In this paper, we assess the explanatory power of hierarchical generative modelling in accounting for TS symptomatology from the perspective of active inference. We propose a fourfold analysis of sensory, motor, and cognitive phenomena associated with TS. In Section 1, we characterise tics as a form of action aimed at sensory attenuation. In Section 2, we introduce the notion of epistemic ticcing and describe such behaviour as the search for evidence that there is an agent (i.e., self) at the heart of the generative hierarchy. In Section 3, we characterise both epistemic (sensation-free) and nonepistemic (sensational) tics as habitual behaviour. Finally, in Section 4, we propose that ticcing behaviour involves an inevitable conflict between distinguishable aspects of selfhood; namely, between the minimal phenomenal sense of self-which is putatively underwritten by interoceptive inference-and the explicit preferences that constitute the individual's conceptual sense of self. In sum, we aim to provide an empirically informed analysis of TS symptomatology under active inference, revealing a continuity between covert and overt features of the condition.

Treating Tourette Together: An Agenda for Patient-Centered Research Focused on Comprehensive Behavioral Intervention for Tics

To establish a patient-centered agenda for research that will lead to effective, widespread availability, adoption, and utilization of evidence-based behavioral treatment of Tourette syndrome and other tic disorders (TDs), we planned and executed a multistage, collaborative "Treating Tourette Together" research planning project with researchers, clinicians, patients, families, and other interested parties. Priorities for future behavioral treatment research were solicited from these parties via anonymous community surveys, a 2-day research planning summit with 46 individuals representing key stakeholder groups, and community response to summit reports. Four high-priority research domains were identified: (a) expanding treatment access, (b) improving treatment outcomes, (c) optimizing treatment within a broader care model, and (d) evaluating outcomes beyond tic severity. Community-engaged participatory research models can efficiently delineate clear and actionable priorities for clinical research. This approach holds promise for improving the impact of clinical research in TDs and other neuropsychiatric disorders.

An Update on the Diagnosis and Management of Tic Disorders

Tic disorders (TDs) are a group of common neuropsychiatric disorders of childhood and adolescence. TDs may impact the physical, emotional, and social well-being of the affected person. In this review, we present an update on the clinical manifestations, pathophysiology, diagnosis, and treatment of TDs. We searched the PubMed database for articles on tics and Tourette syndrome. More than 400 articles were reviewed, of which 141 are included in this review. TDs are more prevalent in children than in adults and in males than in females. It may result from a complex interaction between various genetic, environmental, and immunological factors. Dysregulation in the cortico-striato-pallido-thalamo-cortical network is the most plausible pathophysiology resulting in tics. TD is a clinical diagnosis based on clinical features and findings on neurological examination, especially the identification of tic phenomenology. In addition to tics, TD patients may have sensory features, including premonitory urge; enhanced and persistent sensitivity to non-noxious external or internal stimuli; and behavioral manifestations, including attention deficit hyperactivity disorders, obsessive-compulsive disorders, and autism spectrum disorders. Clinical findings of hyperkinetic movements that usually mimic tics have been compared and contrasted with those of TD. Patients with TD may not require specific treatment if tics are not distressing. Psychoeducation and supportive therapy can help reduce tics when combined with medication. Dispelling myths and promoting acceptance are important to improve patient outcomes. Using European, Canadian, and American guidelines, the treatment of TD, including behavioral therapy, medical therapy, and emerging/experimental therapy, has been discussed.

Online remote behavioural intervention for tics in 9- to 17-year-olds: the ORBIT RCT with embedded process and economic evaluation

Background

Behavioural therapy for tics is difficult to access, and little is known about its effectiveness when delivered online.

Objective

To investigate the clinical and cost-effectiveness of an online-delivered, therapist- and parent-supported therapy for young people with tic disorders.

Design

Single-blind, parallel-group, randomised controlled trial, with 3-month (primary end point) and 6-month post-randomisation follow-up. Participants were individually randomised (1 : 1), using on online system, with block randomisations, stratified by site. Naturalistic follow-up was conducted at 12 and 18 months post-randomisation when participants were free to access non-trial interventions. A subset of participants participated in a process evaluation.

Setting

Two hospitals (London and Nottingham) in England also accepting referrals from patient identification centres and online self-referrals.

Participants

Children aged 9-17 years (1) with Tourette syndrome or chronic tic disorder, (2) with a Yale Global Tic Severity Scale-total tic severity score of 15 or more (or > 10 with only motor or vocal tics) and (3) having not received behavioural therapy for tics in the past 12 months or started/stopped medication for tics within the past 2 months.

Interventions

Either 10 weeks of online, remotely delivered, therapist-supported exposure and response prevention therapy (intervention group) or online psychoeducation (control).

Outcome

Primary outcome: Yale Global Tic Severity Scale-total tic severity score 3 months post-randomisation; analysis done in all randomised patients for whom data were available. Secondary outcomes included low mood, anxiety, treatment satisfaction and health resource use. Quality-adjusted life-years are derived from parent-completed quality-of-life measures. All trial staff, statisticians and the chief investigator were masked to group allocation.

Results

Two hundred and twenty-four participants were randomised to the intervention (n = 112) or control (n = 112) group. Participants were mostly male (n = 177; 79%), with a mean age of 12 years. At 3 months the estimated mean difference in Yale Global Tic Severity Scale-total tic severity score between the groups adjusted for baseline and site was -2.29 points (95% confidence interval -3.86 to -0.71) in favour of therapy (effect size -0.31, 95% confidence interval -0.52 to -0.10). This effect was sustained throughout to the final follow-up at 18 months (-2.01 points, 95% confidence interval -3.86 to -0.15; effect size -0.27, 95% confidence interval -0.52 to -0.02). At 18 months the mean incremental cost per participant of the intervention compared to the control was £662 (95% confidence interval -£59 to £1384), with a mean incremental quality-adjusted life-year of 0.040 (95% confidence interval -0.004 to 0.083) per participant. The mean incremental cost per quality-adjusted life-year gained was £16,708. The intervention was acceptable and delivered with high fidelity. Parental engagement predicted child engagement and more positive clinical outcomes.

Harms

Two serious, unrelated adverse events occurred in the control group.

Limitations

We cannot separate the effects of digital online delivery and the therapy itself. The sample was predominately white and British, limiting generalisability. The design did not compare to face-to-face services.

Conclusion

Online, therapist-supported behavioural therapy for young people with tic disorders is clinically and cost-effective in reducing tics, with durable benefits extending up to 18 months.

Future work

Future work should compare online to face-to-face therapy and explore how to embed the intervention in clinical practice.

Trial registration

This trial is registered as ISRCTN70758207; ClinicalTrials.gov (NCT03483493). The trial is now complete.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Technology Assessment programme (project number 16/19/02) and will be published in full in Health and Technology Assessment; Vol. 27, No. 18. See the NIHR Journals Library website for further project information.

Creative thinking in Tourette's syndrome: A comparative study of patients and healthy controls

INTRODUCTION

Tourette's syndrome is a neurological disorder characterized by tics, that may interfere with patients' everyday life. Research suggested that creative thinking (namely, divergent and convergent thinking) could help patients cope with their symptoms, and therefore it can be a resource in non-pharmacological interventions. The present study aimed at investigating (i) possible differences in creative thinking between Tourette's syndrome patients and healthy controls and (ii) whether creative thinking can support patients in coping with their symptomatology.

METHODS

A group of 25 Tourette's syndrome patients and 25 matched healthy controls underwent an assessment of creative thinking, fluid intelligence, and depressive symptoms. Creative thinking was compared between patients and healthy controls after controlling for fluid intelligence and depressive symptoms. Moreover, the moderating role of divergent and convergent thinking on the subjective impact of tics was tested in a group of 30 patients.

RESULTS

Tourette's syndrome patients outperformed healthy controls in convergent thinking. Moreover, divergent thinking was found as a significant moderator of the relationship between tics severity and the subjective impact in Tourette's syndrome patients.

CONCLUSIONS

Findings highlighted the specific impact of convergent and divergent thinking on Tourette's syndrome patients. Considering the supportive role of creative thinking in Tourette's syndrome, our results confirm that higher levels of divergent thinking may reduce the tic-related discomfort. These findings suggest the potential positive implications of creative thinking in non-pharmacological interventions for Tourette's syndrome.

Cognitive and Neural Mechanisms of Behavior Therapy for Tics: A Perception-Action Integration Approach

European clinical guidelines recommend the use of Exposure and Response Prevention (ERP) and Comprehensive Behavioral Intervention for Tics (CBIT) as first-line treatments for tic disorders. Although ongoing efforts in research are being made to understand the mechanisms underlying these behavioral approaches, as of yet, the neurophysiological mechanisms behind behavioral interventions are poorly understood. However, this is essential to tailor interventions to individual patients in order to increase compliance and efficacy. The Theory of Event Coding (TEC) and its derivative BRAC (Binding and Retrieval in Action Control) provide a theoretical framework to investigate cognitive and neural processes in the context of tic disorders. In this context, tics are conceptualized as a phenomenon of enhanced perception-action binding, with premonitory urges constituting the perceptual and the motor or vocal expression constituting the action part of an event file. Based on this, CBIT is assumed to strongly affect stimulus-response binding in the context of response selection, whereas the effects of ERP presumably unfold during stimulus-response binding in the response inhibition context. Further studies are needed to clarify the neurophysiological processes underlying behavioral interventions to enable the individualization and further development of therapeutic approaches for tic disorders.

Behavioral Interventions for Children and Adults with Tic Disorder

Over the past decade, behavioral interventions have become increasingly recognized and recommended as effective first-line therapies for treating individuals with tic disorders. In this article, we describe a basic theoretical and conceptual framework through which the reader can understand the application of these interventions for treating tics. The three primary behavioral interventions for tics with the strongest empirical support (habit reversal, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention) are described. Research on the efficacy and effectiveness of these treatments is summarized along with a discussion of the research evaluating the delivery of these treatments in different formats and modalities. The article closes with a review of the possible mechanisms of change underlying behavioral interventions for tics and areas for future research.

Art as relaxation for tic disorders: a pilot randomised control study

BACKGROUND

Despite the known benefits of art therapy, there are a limited number of studies on art therapy for tic disorders. This pilot randomised controlled study investigated effects of art as a relaxation technique for tic disorders.

METHODS

Twenty-two children aged 7-9 years were randomly allocated to art intervention (n= 11) and control (n= 11) groups. Pre- and post-test measurements included the Yale Global Tic Severity Scale (YGTSS), Heart Rate Variability (HRV), and Hassles Scale for Children (HSC).

RESULTS

Art as relaxation significantly decreased the YGTSS total score, motor tic frequency, motor tic intensity, motor tic complexity, vocal tic complexity, and total daily stressors compared to the control group. The intervention group showed significantly greater physiological relaxation, as indicated by increases in HRV parameters.

CONCLUSIONS

Art appears to be an effective relaxation technique for tic disorders. Extensive research is necessary for rigorous examination of its effectiveness.

Trends of Tourette Syndrome in children from 2011 to 2021: A bibliometric analysis

Objective

Analyze the research status of Tourette Syndrome (TS) in children by CiteSpace and determine the current research hotspots and frontiers.

Materials and methods

We chose publications indexed in the Web of Science Core Collection (WoSCC) database for studies related to TS in children from 2011 to 2021. We built online cooperation maps of countries/regions, institutions, authors, journals, references, and keywords by CiteSpace, and identified hotspots and frontiers of study for children’s TS.

Results

A total of 1,232 publications about TS in children were downloaded from the WoSCC. The USA (414) was the country with the highest rate of production, and University College London (87) was the institution that had the highest publication rate. Andrea Eugenio Cavanna was the most prolific author (39 papers). There was inactive cooperation between institutions, countries/regions, and authors. The Journal of European Child & Adolescent Psychiatry was the most active journal. Hot topics focused on epidemiology, comorbidities, deep brain stimulation, behavioral therapy, basal ganglia, pharmacological treatment, and risk factors of TS in children.

Conclusion

According to the CiteSpace results, this study found that authors, countries/regions, and institutions were not actively working together. Current research hotspots mainly consist of epidemiology, comorbidities, deep brain stimulation, behavior therapy, and basal ganglia. The main research trends include comorbidities, pharmacological treatment, and risk factors. Therefore, international cooperation should be strengthened in the future, and it should be mindful of the psychiatric comorbidities of TS, the choice of intervention measures, and early warning of risk factors.

Neurosurgical management of Tourette syndrome: A literature review and analysis of a case series treated with deep brain stimulation

Tourette syndrome (TS) is a heterogeneous disorder, which clinical presentation includes both multiple motor and vocal tics and commonly associated psychiatric conditions (obsessive-compulsive disorder, attention deficit hyperactivity disorder, depression, anxiety, etc.). Treatment options primarily consist of non-pharmacological interventions (habit reversal training, relaxation techniques, cognitive behavioral therapy, and social rehabilitation) and pharmacotherapy. In case of the intractable forms, neurosurgical treatment may be considered, primarily deep brain stimulation (DBS). DBS appear to be effective in medically intractable TS patients, although, the preferential brain target is still not defined. The majority of studies describe small number of cases and the issues of appropriate patient selection and ethics remain to be clarified. In this article, we review the main points in management of TS, discuss possible indications and contraindications for neurosurgical treatment, and analyze our experience of DBS in a case series of refractory TS patients with the focus on target selection and individual outcomes.

Long-term Outcomes of Behavior Therapy for Youth With Tourette Disorder

OBJECTIVE

To determine the long-term durability of behavior therapy for tics among youth with Tourette disorder and persistent (chronic) motor or vocal tic disorders.

METHOD

Of the 126 youth who participated in a randomized controlled trial of behavior therapy 11 years prior, 80 were recruited for this longitudinal follow-up. Consenting participants were interviewed in person or remotely (Web-based video) by trained evaluators to determine the course of tics, current tic severity, and tic-related impairment. Recruitment and data collection occurred between 2014 and 2019, with an average follow-up duration of 11.2 years.

RESULTS

Treatment responders to both conditions in the original trial achieved partial, but not full, tic remission. Tic severity also decreased significantly across the sample, with 40% reporting partial remission. Behavior therapy responders (n = 21) in the original trial were more likely (67%) to achieve remission at follow-up (Total Tic Score = 12.52, SD = 10.75) compared to psychoeducation/supportive therapy responders (n = 6, 0%) at follow-up (Total Tic Score = 20.67, SD = 6.92) on the Yale Global Tic Severity Scale. Tic-related impairment decreased across the sample, with no significant differences between treatment groups or responders.

CONCLUSION

Despite limitations of unmeasured variables and veracity of self-report at follow-up, this study supports guidelines recommending behavior therapy as the first-line intervention for tics. Further investigation of behavior therapy as an early preventive intervention also merits attention.

Group behavioral interventions for tics and comorbid symptoms in children with chronic tic disorders

Exposure and Response Prevention (ERP), Habit Reversal Training (HRT) and Comprehensive Behavioral Intervention for Tics (CBIT) are effective in reducing tic severity. ERP and HRT have recently gained primary support in a group setting, while CBIT has not been examined similarly. We compared the efficacy of group-CBIT to group-Educational Intervention for Tics (group-EIT) for tics and comorbid symptoms. Children with Tourette Syndrome (TS) or Chronic Tic Disorder (CTD) were randomized to group-CBIT or group-EIT. Tics and comorbid symptoms were assessed in forty-six children pre- and postintervention, and 3-month later. Yale Global Tic Severity Scale (YGTSS) Motor tic severity decreased following both interventions, and was maintained at follow-up for group-CBIT only. The Parent Tic Questionnaire (PTQ) showed significant decrease in total and motor tic severity following group-CBIT only, a gain maintained three months later. YGTSS impairment score decreased following both interventions and was maintained at follow-up. YGTSS vocal tic severity score increased following both interventions, and then decreased significantly at follow up. Co-morbid symptoms including anxiety, behavioral problems, and aggressive behavior decreased following both interventions. Children with behavioral problems benefitted less while children with higher intellectual ability benefit more from intervention. Both group interventions showed efficacy in reducing tic impairment and comorbid symptoms. Group-CBIT was superior to group-EIT in reducing motor tic severity at 3-month follow-up, showing an advantage for tic-focused treatment. Based on the PTQ, group-CBIT was superior to group-EIT in reducing motor, vocal, and total tic scores, a gain maintained three months later. Clinical trial registry information-Group Intervention for Children with Chronic Tics Syndrome: CBIT vs Psychoeducational Intervention URL: http://clinicaltrials.gov , Identifier: NCT02407951, http://www.controlled-trials.com ).

Is Traditional Chinese Medicine Effective in Treating Tic Disorders (Tourette Syndrome)? A Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Traditional Chinese medicine (TCM) is a type of alternative medicine that has been widely utilized in the prevention and treatment of neuropsychiatric diseases such as schizophrenia, ADHD, Alzheimer disease, and Tourette syndrome (TS) in many countries. However, the results regarding TCM's effectiveness and safety in treating TS are conflicting. Therefore, the goal of the present study is to analyze and summarize the available literature related to the efficacy of TCM in the treatment of tic disorders, especially TS.

METHODS

Relevant articles for the meta-analysis were searched using appropriate keywords from PubMed, MEDLINE, and CENTRAL databases. Event data for TCM for the treatment of TS in the control and intervention arms were determined from the randomized controlled trials, and diagnostic odds ratio (DOR) and risk of bias analysis were performed. Meta-analysis was performed using MedCalc software, and suitable parameters to assess heterogeneity were computed.

RESULTS

Twelve randomized clinical trials with a total of 1,681 TS patients were included as per the inclusion criteria. The patients' clinical symptoms were improved to a greater extent, and the pooled DOR of 1.311 with a 95% confidence interval (CI) value ranging from 0.804 to 2.139 and I2 value of 72.04% were obtained. The pooled relative risk was 1.09, with a 95% CI value ranging from 0.97 to 1.268. The data heterogeneity was assessed, and we achieved a Q value of 33.54, a p value of 0.0004, and I2 value of 67.21% with a 95% CI value of 32.91-82.10. All these values are statistically significant, with p < 0.005, and confirmed the effectiveness of TCM for TS patients.

CONCLUSION

The present meta-analysis on account of these statistically significant results highly recommends using TCM to treat TS.

The Efficacy of Cognitive Behavioral Therapy for Tic Disorder: A Meta-Analysis and a Literature Review

Background

At present, tic disorder has attracted the attention of medical researchers in many countries. More clinicians choose non-drug therapy, especially cognitive-behavioral therapy (CBT) because of the cognitive side effects of drug therapy. However, few studies had assessed its efficacy. It is necessary to have a more comprehensive understanding of the literature quality of CBT and its intervention effect.

Methods

In this study, MEDLINE, Embase, and Cochrane were searched from the beginning to June 15, 2021 to study the efficacy of -CBT on tic disorder. Only studies using the Yale Global Tic Severity Scale (YGTSS) and the control group were included.

Results

A total of 12 randomized controlled trials (RCTs), including 536 patients with tic disorders, were identified. The results showed that the effect of CBT was better than that of the control group. The pooled standardized mean difference (SMD) was −0.34 (95% CI: −0.61, −0.07). The effect size of CBT differs from different intervention conditions. In seven studies, the subjects’ motor tic scores were counted. The sample size of the experimental group was 224 and that of the control group was 218. The pooled SMD was −0.43 (95% CI: −0.75, −0.11). Seven studies counted the vocal tic scores of subjects, 224 in the experimental group and 218 in the control group. The pooled SMD was −0.22 (95% CI: −0.54, −0.11). Seven studies counted the tic impairment scores of subjects, 220 in the experimental group and 214 in the control group. The pooled SMD was −0.48 (95% CI: −0.73, −0.23).

Conclusion

The literature shows that different CBTs can significantly reduce the total score of tic disorder and the score of motor tic, but cannot significantly reduce the score of vocal tic. In the future, more new interventions were needed to improve the symptoms of different patients, especially vocal tic.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part I: assessment

In 2011 a working group of the European Society for the Study of Tourette Syndrome (ESSTS) has developed the first European assessment guidelines for Tourette syndrome (TS). Now, we present an updated version 2.0 of these European clinical guidelines for Tourette syndrome and other tic disorders, part I: assessment. Therefore, the available literature has been thoroughly screened, supplemented with national guidelines across countries and discussions among ESSTS experts. Diagnostic changes between DSM-IV and DSM-5 classifications were taken into account and new information has been added regarding differential diagnoses, with an emphasis on functional movement disorders in both children and adults. Further, recommendations regarding rating scales to evaluate tics, comorbidities, and neuropsychological status are provided. Finally, results from a recently performed survey among ESSTS members on assessment in TS are described. We acknowledge that the Yale Global Tic Severity Scale (YGTSS) is still the gold standard for assessing tics. Recommendations are provided for scales for the assessment of tics and psychiatric comorbidities in patients with TS not only in routine clinical practice, but also in the context of clinical research. Furthermore, assessments supporting the differential diagnosis process are given as well as tests to analyse cognitive abilities, emotional functions and motor skills.

Relaxation training with and without Comprehensive Behavioral Intervention for Tics for Tourette's disorder: A multiple baseline across participants consecutive case series

BACKGROUND AND OBJECTIVES

Behavioral therapies such as the Comprehensive Behavioral Intervention for Tics (CBIT) are recommended as the first-line treatment for Tourette's Disorder. This treatment approach is comprised of three central components: habit reversal training, functional assessment/intervention, and relaxation training. Despite its combined efficacy, the contribution of each therapeutic component in CBIT for reducing tic severity remains undetermined. The study evaluated the efficacy of relaxation training alone or alongside other CBIT components for reducing tic severity.

METHODS

In this multiple-baseline study, participants completed a baseline assessment (A), 4 weekly sessions of relaxation training followed by a posttreatment assessment (B), 8 weekly sessions of CBIT followed by a posttreatment assessment (C), and a 1 month posttreatment follow up assessment (D). Six participants (83% male) aged 10-18 with Tourette's Disorder completed study procedures. Primary outcomes of tic severity was the Yale Global Tic Severity Scale (YGTSS).

RESULTS

A repeated measures ANOVA revealed a significance reduction in tic severity over time (p = .010). While post-hoc tests revealed a moderate non-significant reduction in tic severity after relaxation training (d =.23), large significant reductions in tic severity were observed after the combined treatment of relaxation training and CBIT (d = 1.17) that were maintained at a 1-month follow-up visit (d = 1.53).

LIMITATIONS

Findings are limited by the small sample size.

CONCLUSIONS

While relaxation training is effective when included in conjunction with CBIT, relaxation training alone is not effective in reducing tic severity in patients with Tourette's Disorder.

We Move or Are We Moved? Unpicking the Origins of Voluntary Movements to Better Understand Semivoluntary Movements

The capacity for voluntary control is seen as essential to human movements; the sense that one intended to move (willing) and those actions were self-generated (self-agency) gives the sense of voluntariness and of being in control. While the mechanisms underlying voluntary movement have long been unclear, recent neuroscientific tools have identified networks of different brain areas, namely, the prefrontal cortex, supplementary motor area, and parietal cortex, that underlie voluntary action. Dysfunction in these brain areas can result in different forms of semivoluntary movement as the borderland of voluntary and involuntary movement where a person may experience a disordered sense of will or agency, and thus the movement is experienced as unexpected and involuntary, for an otherwise voluntary-appearing movement. Tics, functional movement disorders, stereotypies, perseveration, compulsions, utilization behaviors, and motor mannerism have been described elsewhere in the context of psychoses, and are often mistaken for each other. Yet, they reflect an impairment of prefrontal cortices and related circuits rather than simple motor systems, which results in the absence of subjective recognition of the movements, in contrast to other neurological movement disorders where principal abnormalities are located within the basal ganglia and its connections. Therefore, their recognition is clinically important since they are usually associated with neurodevelopmental and neurodegenerative disorders. In this review, we first defined a conceptual framework, from both a neuroanatomical and a neurophysiological point of view, for the generation of voluntary movement. We then examined the evidence linking dysfunctions in different motor pathways to each type of movement disorder. We looked at common semivoluntary movement disorders providing an overview, where possible, of their phenomenology and brain network abnormalities for each condition. We also emphasized important clinical feature similarities and differences to increase recognition of each condition in practice.

Inhibitory Control in Children with Tourette Syndrome Is Impaired in Everyday Life but Intact during a Stop Signal Task

Tourette Syndrome (TS) has previously been associated with deficits in inhibitory control (IC). However, studies on IC in individuals with TS have produced conflicting results. In the present study, we investigated IC, comparing the Stop Signal Reaction Time (SSRT) measure with parent and teacher ratings of daily life IC in 169 children aged 8–12 (60 with TS, 60 typically developing controls, 27 with attention-deficit/hyperactivity disorder (ADHD), and 22 with TS + ADHD). We further investigated associations of IC with TS and ADHD symptom severity. Children with TS showed intact SSRT performance, but impairments in daily life IC, as reported by parents and teachers. For the latter, we observed a staircase distribution of groups, with the healthy controls presenting with the best IC, followed by TS, TS + ADHD, and finally ADHD. Dimensional analyses indicated a strong association between ADHD severity and both measures of IC. Our results indicate that children with TS are not impaired in a laboratory-based measure of IC, although some difficulties were evident from measures of everyday behaviour, which may in part be due to parents and teachers interpreting tics as disinhibited behaviour. Comorbid ADHD or the severity of subthreshold ADHD symptomatology appeared to account for IC deficits.

European clinical guidelines for Tourette syndrome and other tic disorders: summary statement

In 2011 a working group of the European Society for the Study of Tourette syndrome (ESSTS) developed the first European Guidelines for Tourette syndrome (TS) published in the ECAP journal. After a decade ESSTS now presents updated guidelines, divided into four sections: Part I: assessment, Part II: psychological interventions, Part III: pharmacological treatment and Part IV: deep brain stimulation (DBS). In this paper, we summarise new developments described in the guidelines with respect to assessment and treatment of tics. Further, summary findings from a recent survey conducted amongst TS experts on these same topics are presented, as well as the first European patient representative statement on research. Finally, an updated decision tree is introduced providing a practical algorithm for the treatment of patients with TS. Interestingly, in the last decade there has been a significant shift in assessment and treatment of tics, with more emphasis on non-pharmacological treatments.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part IV: deep brain stimulation

In 2011 the European Society for the Study of Tourette Syndrome (ESSTS) published its first European clinical guidelines for the treatment of Tourette Syndrome (TS) with part IV on deep brain stimulation (DBS). Here, we present a revised version of these guidelines with updated recommendations based on the current literature covering the last decade as well as a survey among ESSTS experts. Currently, data from the International Tourette DBS Registry and Database, two meta-analyses, and eight randomized controlled trials (RCTs) are available. Interpretation of outcomes is limited by small sample sizes and short follow-up periods. Compared to open uncontrolled case studies, RCTs report less favorable outcomes with conflicting results. This could be related to several different aspects including methodological issues, but also substantial placebo effects. These guidelines, therefore, not only present currently available data from open and controlled studies, but also include expert knowledge. Although the overall database has increased in size since 2011, definite conclusions regarding the efficacy and tolerability of DBS in TS are still open to debate. Therefore, we continue to consider DBS for TS as an experimental treatment that should be used only in carefully selected, severely affected and otherwise treatment-resistant patients.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part III: pharmacological treatment

In 2011, the European Society for the Study of Tourette Syndrome (ESSTS) published the first European guidelines for Tourette Syndrome (TS). We now present an update of the part on pharmacological treatment, based on a review of new literature with special attention to other evidence-based guidelines, meta-analyses, and randomized double-blinded studies. Moreover, our revision took into consideration results of a recent survey on treatment preferences conducted among ESSTS experts. The first preference should be given to psychoeducation and to behavioral approaches, as it strengthens the patients' self-regulatory control and thus his/her autonomy. Because behavioral approaches are not effective, available, or feasible in all patients, in a substantial number of patients pharmacological treatment is indicated, alone or in combination with behavioral therapy. The largest amount of evidence supports the use of dopamine blocking agents, preferably aripiprazole because of a more favorable profile of adverse events than first- and second-generation antipsychotics. Other agents that can be considered include tiapride, risperidone, and especially in case of co-existing attention deficit hyperactivity disorder (ADHD), clonidine and guanfacine. This view is supported by the results of our survey on medication preference among members of ESSTS, in which aripiprazole was indicated as the drug of first choice both in children and adults. In treatment resistant cases, treatment with agents with either a limited evidence base or risk of extrapyramidal adverse effects might be considered, including pimozide, haloperidol, topiramate, cannabis-based agents, and botulinum toxin injections. Overall, treatment of TS should be individualized, and decisions based on the patient's needs and preferences, presence of co-existing conditions, latest scientific findings as well as on the physician's preferences, experience, and local regulatory requirements.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part II: psychological interventions

Part II of the European clinical guidelines for Tourette syndrome and other tic disorders (ECAP journal, 2011) provides updated information and recommendations for psychological interventions for individuals with tic disorders, created by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain original studies of psychological interventions for tic disorders, published since the initial European clinical guidelines were issued. Relevant studies were identified using computerized searches of the MEDLINE and PsycINFO databases for the years 2011-2019 and a manual search for the years 2019-2021. Based on clinical consensus, psychoeducation is recommended as an initial intervention regardless of symptom severity. According to a systematic literature search, most evidence was found for Habit Reversal Training (HRT), primarily the expanded package Comprehensive Behavioral Intervention for Tics (CBIT). Evidence was also found for Exposure and Response Prevention (ERP), but to a lesser degree of certainty than HRT/CBIT due to fewer studies. Currently, cognitive interventions and third-wave interventions are not recommended as stand-alone treatments for tic disorders. Several novel treatment delivery formats are currently being evaluated, of which videoconference delivery of HRT/CBIT has the most evidence to date. To summarize, when psychoeducation alone is insufficient, both HRT/CBIT and ERP are recommended as first-line interventions for tic disorders. As part of the development of the clinical guidelines, a survey is reported from ESSTS members and other tic disorder experts on preference, use and availability of psychological interventions for tic disorders.

Implementation and Evaluation of Therapeutic Online Coaching Using Habit Reversal Training in Children With Tourette's Disorder - A Pilot Study

Cognitive-behavioral interventions can be difficult to implement in daily routine, which is often essential for generalizing treatment effects to natural settings. Furthermore, there is a lack of adequate care options concerning habit reversal training for children with Tourette’s disorder. The objective of this study is to evaluate therapeutic online coaching via videoconferencing in the natural environment of children with Tourette’s disorder in addition to face-to-face therapy (blended therapy). Online coaching took place twice a week for a maximum of 12 weeks. In a single-case study (n = 5; patients aged 8–11 years), the first results were obtained for exploratory purposes, especially with regard to the feasibility and reduction of symptoms and impairment. Various outcome measures were assessed (severity of symptoms, impairment, practical implementation, and satisfaction). Despite some principal limitations, the findings provide first hints that blended therapy is feasible and improves symptoms in some children with tics.

Clinical Trial Registration: [https://clinicaltrials.gov/], identifier [DRKS00017199].

Role of psychotherapy strategy for the management of patients with Tourette syndrome - A Bayesian network meta-analysis

Tourette's syndrome (TS) is a complex neurodevelopmental disorder characterized by high comorbidity. Treatment with psychotherapy is highly recommended, however, there exists limited available evidence on the use and the optimal psychotherapeutic outcome is debatable. We performed a systematic search on several bibliographic databases for randomized controlled trials (RCTs) reporting the use of psychotherapy treatment in TS patients, from inception to August 1st, 2020, and without language restrictions. Outcome measures were measured by the Yale global tic severity scale (YGTSS) to determine the efficacy of psychotherapy. Data were pooled as Standard mean difference (SMD) in the Bayesian analysis of the random effect model. A total of 17 RCTs with 9 treatments and 1042 participants were included from an initial 4901 records. The primary outcome including, Comprehensive behavioral intervention (CBIT) [SMD = -1.43, 95%Credible interval (CrI): -2.39, -0.44], Exposure with response prevention (ERP) [SMD = -1.37, 95%CrI: -2.62, -0.13], Habit reversal therapy (HRT) [SMD = -0.93, 95%CrI: 1.83, -0.05], and Behavior therapy (BT) [SMD = -0.85, 95%CrI: 1.51, -0.18], were found to be significantly lower in the TS group compared with the control group (including wait-list, treatment-as-usual or other named control group). Based on the Surface under the cumulative ranking curve (SUCRA), CBIT (SUCRA value = 86.97%, 95%CrI: 44%, 100%) was found to be a suitable psychotherapeutic treatment for TS patients. High-quality RCTs on psychotherapy are needed to perform for establishing the foundation of the generation of evidence-based guidelines.

Living with tics: Nursing Care of Pediatric Tourette Syndrome

Tourette syndrome (TS) is a neurodevelopmental movement characterized by abrupt, rapid, repetitive, and non-rhythmic tics. While TS is not life-threatening, such tics and comorbidities affect a children's physical and mental health and social interactions. Treatment is necessary when the children experience physical discomfort, functional dysfunction, and poor interpersonal interaction and mental health. Common management strategies for TS include psychological interventions and pharmacological treatment. Additionally, it is important to consider the individual needs of youths with TS and reassess the treatment outcomes and the need to receive continuous treatment regularly. This review summarizes the symptom management and nursing care measures for youths with TS. Understanding and listening to the healthcare problems of youths with TS can help providers develop healthcare interventions tailored to the youths' needs. Providing the youths with strategies to reduce the tics' interference with their learning outcomes and helping them develop strategies to cope with diverse interpersonal interactions at school are also important. Further, enhancing acceptance given by parents, teachers, and peers, as well as improving the general public's understanding of TS are important measures that promote the youths' social adjustment as well as their ability to coexist with TS.

Efficacy and cost-effectiveness of therapist-guided internet-delivered behaviour therapy for children and adolescents with Tourette syndrome: study protocol for a single-blind randomised controlled trial

BACKGROUND

Treatment guidelines recommend behaviour therapy (BT) for patients with Tourette syndrome (TS) and chronic tic disorder (CTD). However, BT is rarely accessible due to limited availability of trained therapists and long travel distances to specialist clinics. Internet-delivered BT has the potential of overcoming these barriers through remote delivery of treatment with minimal therapist support. In the current protocol, we outline the design and methods of a randomised controlled trial (RCT) evaluating an internet-delivered BT programme referred to as BIP TIC. The trial's primary objective is to determine the clinical efficacy of BIP TIC for reducing tic severity in young people with TS/CTD, compared with an active control intervention. Secondary objectives are to investigate the 12-month durability of the treatment effects and to perform a health economic evaluation of the intervention.

METHODS

In this single-blind superiority RCT, 220 participants (9-17 years) with TS/CTD throughout Sweden will be randomised to 10-12 weeks of either therapist-supported internet-delivered BT based on exposure with response prevention (BIP TIC) or therapist-supported internet-delivered education. Data will be collected at baseline, 3 and 5 weeks into the treatment, at post-treatment, and 3, 6, and 12 months post-treatment. The primary endpoint is the 3-month follow-up. The primary outcome is tic severity as measured by the Yale Global Tic Severity Scale - Total Tic Severity Score. Treatment response is operationalised as scores of "Very much improved" or "Much improved" on the Clinical Global Impression - Improvement scale, administered at the primary endpoint. Outcome assessors will be blind to treatment condition at all assessment points. A health economic evaluation of BIP TIC will be performed, both in the short term (primary endpoint) and the long term (12-month follow-up). There are no planned interim analyses.

DISCUSSION

Participant recruitment started on 26 April 2019 and finished on 9 April 2021. The total number of included participants was 221. The final participant is expected to reach the primary endpoint in September 2021 and the 12-month follow-up in June 2022. Data analysis for the primary objective will commence after the last participant reaches the primary endpoint.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03916055 . Registered on 16 April 2019.

Recent progress on Tourette syndrome

Tic disorders and Tourette syndrome are the most common movement disorders in children and are characterized by movements or vocalizations. Clinically, Tourette syndrome is frequently associated with comorbid psychiatric symptoms. Although dysfunction of cortical–striatal–thalamic–cortical circuits with aberrant neurotransmitter function has been considered the proximate cause of tics, the mechanism underlying this association is unclear. Recently, many studies have been conducted to elucidate the epidemiology, clinical course, comorbid symptoms, and pathophysiology of tic disorders by using laboratory studies, neuroimaging, electrophysiological testing, environmental exposure, and genetic testing. In addition, many researchers have focused on treatment for tics, including behavioral therapy, pharmacological treatment, and surgical treatment. Here, we provide an overview of recent progress on Tourette syndrome.

Pharmacological treatment for Tourette syndrome in children and adults: What is the quality of the evidence? A systematic review

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental disorder characterised by involuntary muscle movements manifesting as motor and vocal tics. In the majority, tics are manageable without medication. Where tics cause discomfort or impair function, behavioural or pharmaceutical treatments may be considered.

AIMS

To provide a meticulous examination of the quality of evidence for the current pharmacological treatments for TS.

METHODS

PubMed and Google Scholar were searched to identify randomised, placebo-controlled trials (RCTs) of aripiprazole, risperidone, clonidine, guanfacine, haloperidol, pimozide, tiapride and sulpiride for the treatment of tics in children and adults with TS. Quality of reporting and risk of bias were assessed against the CONSORT checklist and Cochrane risk of bias criteria, respectively.

RESULTS

Seventeen RCTs were identified. Response rates reached 88.6% for aripiprazole, 68.9% for clonidine, 62.5% for risperidone and 19% for guanfacine. Statistically significant improvements were reported for all medications compared to placebo in at least one study and for at least one measure of tic severity. Most studies predated the CONSORT and Cochrane criteria and did not score highly when assessed on these measures.

CONCLUSIONS

There are relatively few placebo-controlled trials of commonly prescribed medications. Studies are often of poor quality and short duration. There is evidence for the efficacy of each medication, but no drug is clearly superior. Clonidine and guanfacine are better tolerated than antipsychotics, but less effective. There is too little evidence to determine whether adults respond differently from children.

Nonpharmacological treatments for Tourette syndrome and tic disorders: A protocol for systematic review and network meta-analysis

BACKGROUND

A tic is a sudden, rapid, recurrent, nonrhythmic motor movement, or vocalization. Tic disorders are diagnosed based on the presence of motor or vocal tics, duration of tic symptoms, and age at onset. Current clinical practice guidelines strongly recommend behavioral therapies because they are more effective and safer than medications. To determine the most effective nonpharmacological intervention for tic disorders and Tourette syndrome, we will conduct a systematic review and network meta-analysis.

METHODS

We will search the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycARTICLES, AMED, 3 Chinese databases (China National Knowledge Infrastructure, Chongqing VIP, and Wanfang Data), 3 Korean databases (Korean Medical Database, Korean studies Information Service System, and ScienceON), and a Japanese database (CiNii). There will be no language or date restrictions. The primary outcome will be the tic severity scale, the Yale Global Tic Severity Scale. The secondary outcomes will include the effective rate defined by the trial authors, dropout rate, and adverse events. Methodological quality will be assessed using the Cochrane risk of bias tool.

RESULTS

Results of this review and network meta-analysis will be published in a peer-reviewed journal.

CONCLUSIONS

This systematic review will assess the effectiveness of nonpharmacological interventions for treating tic disorders. A systematic review or meta-analysis will provide an unbiased overview of the existing evidence.

Clinical efficacy and safety of acupuncture treatment of TIC disorder in children: A systematic review and meta-analysis of 22 randomized controlled trials

OBJECTIVE

To systematically evaluate the clinical efficacy and safety of acupuncture in the treatment of Tic Disorders (TD) in children, and to clarify the current evidence regarding the clinical application of acupuncture in the treatment of TD.

METHODS

Randomized controlled trials (RCTs) comparing acupuncture treatment with pharmaceutical treatment for TD were included in this review. A comprehensive search of 6 electronic literature databases was conducted, and the retrieval date was from the establishment of the database to April 2020. The Cochrane Collaboration's bias risk assessment tool was used to evaluate the bias risk of the included literature, and adopted the Review Manager 5.3 was used for statistical analysis of the data in the included literature.

RESULTS

A total of 22 RCTs (1668 participants) were included in this review. Meta-analysis indicated that acupuncture showed superior effects in the following aspects, including higher overall effective rate [RR = 1.20,95 % CI(1.09,1.20),P＜0.00001], significant reduction in Yale Global Tic Severity Scale (YGTSS) scores [MD=-2.79,95 %CI(-4.75,-0.82),P = 0.005], lower incidence of adverse effects [RR = 0.26,95 %CI(0.17,0.41),P＜0.00001], and reduced recurrence rate [RR = 0.28,95 %CI(0.17,0.46),P＜0.00001].

CONCLUSION

Acupuncture treatment alone is more effective in the treatment of TD than pharmaceutical treatment, as seen in the reduction of YGTSS scores, fewer adverse effects and lower recurrence rates.

Homework adherence predicts therapeutic improvement from behavior therapy in Tourette's disorder

Behavior therapy is a first-line intervention for Tourette's Disorder (TD), and a key component is the practice of therapeutic skills between treatment visits (i.e., homework). This study examined the relationship between homework adherence during behavior therapy for TD and therapeutic outcomes, and explored baseline predictors of homework adherence during treatment. Participants included 119 individuals with TD (70 youth, 49 adults) who received behavior therapy in a clinical trial. After a baseline assessment of tic severity and clinical characteristics, participants received 8 sessions of behavior therapy. Therapists recorded homework adherence at each therapy session. After treatment, tic severity was re-assessed by independent evaluators masked to treatment condition. Greater overall homework adherence predicted tic severity reductions and treatment response across participants. Early homework adherence predicted therapeutic improvement in youth, whereas late adherence predicted improvement in adults. Baseline predictors of greater homework adherence in youth included lower hyperactivity/impulsivity and caregiver strain. Meanwhile in adults, baseline predictors of increased homework adherence included younger age, lower hyperactivity/impulsivity, obsessive-compulsive severity, anger, and greater work-related disability. Homework adherence is an integral component of behavior therapy and linked to therapeutic improvement. Strategies that improve homework adherence may optimize the efficacy of behavioral treatments and improve treatment outcomes.

Networks in the Field of Tourette Syndrome

Gilles de la Tourette syndrome (TS) is a neuropsychiatric neurodevelopmental disorder with the cardinal clinical features of motor and phonic tics. Clinical phenomenology can be complex since, besides tics, there are other features including premonitory urges preceding tics, pali-, echo-, and coprophenomena, hypersensitivity to external stimuli, and symptom dependency on stress, attention, and other less well-defined factors. Also, the rate of comorbidities, particularly attention deficit hyperactivity disorder and obsessive-compulsive disorder, is high. Mirroring the complexities of the clinical course and phenomenology, pathophysiological findings are very diverse, and etiology is disputed. It has become clear, though, that abnormalities in the basal ganglia and their connections with cortical areas are key for the understanding of the pathophysiology and as regards etiology, genetic factors are crucial. Against this background, both adequate clinical management of TS and TS-related research require multidisciplinary preferably international cooperation in larger groups or networks to address the multiple facets of this disorder and yield valid and useful data. In particular, large numbers of patients are needed for brain imaging and genetic studies. To meet these requirements, a number of networks and groups in the field of TS have developed over the years creating an efficient, lively, and supportive international research community. In this review, we will provide an overview of these groups and networks.

Ticked Off: Anger Outbursts and Aggressive Symptoms in Tourette Disorder

Tourette disorder is a complex neuropsychiatric syndrome of childhood onset characterized by multiple motor and phonic tics and is associated with high rates of psychiatric comorbidity. Symptoms of impulsive aggression (explosive outbursts or "rage") are commonly encountered in the clinical setting, cause significant morbidity, and pose diagnostic and treatment challenges. These symptoms may be multifactorial in etiology and result from a complex interplay of illness severity and psychosocial factors. Treatment strategies require careful differential diagnostic evaluation and include both behavioral and pharmacologic interventions.

A Review of Cognitive and Behavioral Interventions for Tic Disorder

OBJECTIVES

Tic disorder is a neurodevelopmental disorder characterized by multiple involuntary movements of muscles or vocalization. Although tic symptoms subside as the patient ages, some patients suffer from significant functional impairments related to severe tic symptoms. This manuscript aimed to review the latest scientific evidences for the effect of cognitive-behavioral interventions on tic disorder.

METHODS

The relevant studies were identified by searching medical research databases. We focused our search on studies published between 2000 and 2020 in order to reflect the latest scientific evidence. A total of 821 articles were identified in the initial database search and 27 articles were finally included for the review after the exclusion of duplicated and irrelevant articles.

RESULTS

Behavioral therapies including habit reversal training, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention were the most widely studied interventions for tic disorder and are recommended as first-line treatments for tic disorders with high confidence. Cognitive psychophysiologic approaches were also reported to be effective.

CONCLUSION

Further studies are needed to support the future treatment of tics with low-cost and more widely available treatments, in order to ensure better treatment outcomes.

Feasibility and acceptability of an online mindfulness-based group intervention for adults with tic disorders

BACKGROUND

Preliminary research suggests that a mindfulness-based treatment approach may be beneficial for adults with tic disorders. In the present study, we report on the feasibility, acceptability, safety, and symptomatic effect of a novel online mindfulness-based group intervention for adults with Tourette syndrome or persistent tic disorder. Data from this study will directly inform the conduct of a funded randomized controlled trial comparing the efficacy of this intervention to another active psychological intervention.

METHODS

One cohort of adults with Tourette syndrome participated in an 8-week online mindfulness-based group intervention. Measures of feasibility, acceptability, and safety were administered throughout and at posttreatment. Self-reported measures of mindfulness and clinician-rated measures of tic severity and impairment were administered at baseline and posttreatment.

RESULTS

Data on refusal, dropout rate, attendance, participant satisfaction, and safety suggest that this is a feasible and acceptable intervention. However, participant adherence to home practice was lower than anticipated. Mindfulness, tic severity, and tic-related impairment only modestly improved from baseline to posttreatment. Qualitative analysis of participant feedback revealed aspects of the intervention that were most helpful and also areas for improvement.

CONCLUSIONS

Data suggest that although this is a feasible and acceptable intervention, it should be modified to enhance participant adherence, more successfully engage the target mechanism, and optimize outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov registration # NCT03525626 . Registered on 24 April 2018.

Traditional Chinese Medicine Strategy for Patients with Tourette Syndrome Based on Clinical Efficacy and Safety: A Meta-Analysis of 47 Randomized Controlled Trials

OBJECTIVE

Although increasing evidence reveals the efficacy of traditional Chinese medicine (TCM) and its safety on Tourette Syndrome (TS) patients, whether TCM is indeed improving TS remains unclear. The purpose of the current study is to perform a meta-analysis to evaluate the efficacy and safety of TCM on treating TS patients.

METHOD

An elaborate search strategy was conducted based on several databases including Medline, Embase, Cochrane, Web of Science, CINAHL, CBM, VIP, CNKI, and Wanfang Data in order to identify the relevant randomized controlled trials (RCTs) from their inception to as late as May 1st, 2020. General information and data needing analysis were extracted simultaneously for the necessity of various analyses such as descriptive analysis and metaquantitative analysis.

RESULTS

Forty-seven trials with 5437 TS patients in total were eventually included according to our criteria. All trials were conducted in China, and the publication years ranged from 2004 to 2017. In terms of clinical efficacy, clinical symptoms of patients with TCM were more likely to be improved compared with the control group (odds ratio, OR = -1.29, 95% confidence interval, CI: -2.54 to -0.06, I 2 = 0.00%). As to the outcome of recurrence rate, the pooled results revealed that the TCM group was more inclined to stabilize the recurrence (OR = 0.44, 95% CI: 0.24 to 0.78, I 2 = 0.00%). Similar results were observed in adverse reaction (OR = 0.32, 95% CI: 0.24 to 0.43, I 2 = 32.90%).

CONCLUSION

The results of our study recommend applying TCM to treat TS patients for better efficacy and safety. Results need to be interpreted cautiously due to certain limitations in our study.

An International Survey of Health Care Services Available to Patients With Tourette Syndrome

Objective: Tourette syndrome (TS) is a neuropsychiatric disorder that is highly associated with several comorbidities. Given the complex and multifaceted nature of TS, the condition is managed by a wide variety of practitioners in different disciplines. The goal of this study was to investigate health service delivery and care practices by clinicians who see TS patients across different geographic settings internationally. Methods: A comprehensive questionnaire was developed to assess clinical care resources for patients with TS and was sent to clinicians in Canada (CA), the United States (US), Europe (EU), and the United Kingdom (UK). Responses were compared quantitatively between geographic regions. Results: The majority of respondents, regardless of region, reported that fewer than 40% of their case-load are patients with tics. The accessibility of TS services varied among regions, as indicated by differences in wait times, telemedicine offerings, comorbidity management and the availability of behavioral therapies. First-line pharmacotherapy preferences varied among physicians in different geographical regions with CA respondents preferring alpha-2-adrenergic agonists and respondents from the UK and EU preferring dopamine receptor antagonists. Discussion: The results suggest that there is a scarcity of specialized TS clinics, potentially making access to services challenging, especially for patients newly diagnosed with TS. Differences in regional pharmacotherapeutic preferences are reflected in various published treatment guidelines in EU and North America. The lack of dedicated specialists and telemedicine availability, coupled with differences in comorbidity management, highlight the need for interprofessional care and holistic management to improve health care delivery to patients with TS.

Multidisciplinary Telemedicine Care for Tourette Syndrome: Minireview

Tourette syndrome (TS) is a childhood-onset, chronic neuropsychiatric disorder characterized by multiple motor and vocal tics. TS poses a considerable burden on both patients and health care providers, leading to a major detriment of educational success, occupation, and interpersonal relationships. A multidisciplinary, specialist-driven management approach is required due to the complexity of TS. However, access to such specialty care is often dramatically limited by the patients' locations and the specialists' geographic clustering in large urban centers. Telemedicine uses electronic information and communication technology to provide and support health care when distance separates participants. Therefore, we conducted this mini-review to describe the latest information on telemedicine in the assessment and management of TS and discuss the potential contributions to care for TS patients with a multidisciplinary approach. We believe that telemedicine could be a revolutionary method in improving medical access to patients with TS.

Effectiveness of Behaviour Therapy for Children and Adolescents with Tourette Syndrome and Chronic Tic Disorder in a Naturalistic Setting

It is unclear if the results of randomised controlled trials (RCTs) of behaviour therapy (BT) for Tourette syndrome (TS) and chronic tic disorder (CTD) can be generalised to naturalistic clinical settings and are durable long-term. In this naturalistic study, 74 young people with TS/CTD received BT at a specialist clinic. Data were collected at baseline, post-treatment, and at 3-, 6-, and 12-month follow-ups. Measures included the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impression-Improvement scale (CGI-I), amongst others. Tic severity and tic-related impairment improved after treatment, with large within-group effect sizes. At post-treatment, 57% of the participants were classified as treatment responders according to the CGI-I. Tic severity and tic-related impairment improved further through the follow-up, with 75% treatment responders at the 12-month follow-up. BT is an effective and durable treatment for young people with TS/CTD in a naturalistic specialist clinical setting, with comparable effects to RCTs.

Behavior Therapy for the Treatment of Tourette's Disorder in India: A Patient Series from an Indian General Hospital Psychiatric Unit

Reports on behavioral interventions for the treatment of Tourette's disorder (TD) from India are limited. This patient series describes the usefulness and feasibility of conducting behavioral interventions for patients with TD from an Indian general hospital psychiatric unit. Behavioral treatments in these seven consecutively treated adult/adolescent patients with TD included all components of habit reversal treatment, comprehensive behavioral intervention for tics, and exposure with response prevention in some patients. Patients were predominantly male, with adolescent-onset severe TD, typical features and psychiatric comorbidities, and poor response to multiple medications prior to the institution of behavior therapy. In addition to long delays in diagnosis, none of the patients or their caregivers had been informed by the doctors they had consulted earlier about TD or the need for behavioral treatments before attending our center. Institution of behavioral treatments along with medications led to a 75% reduction in the severity of tics and reduction in comorbid symptoms. Patients and caregivers also reported similar rates of improvement as well as reductions in subjective distress and caregiver burden. Five patients have been followed up for seven months to seven years; apart from one patient, all others have had only minor exacerbations of tics during this period. This limited experience suggests that behavior therapies for TD can be successfully implemented in low-resource, non-specialized Indian settings. They are effective, and gains from such treatment are usually enduring.

Tackle your Tics: pilot findings of a brief, intensive group-based exposure therapy program for children with tic disorders

Tourette syndrome (TS) and other chronic tic disorders (CTD) are prevalent neurodevelopmental disorders, which can have a huge burden on families and society. Behavioral treatment is a first-line intervention for tic disorders. Despite demonstrated efficacy, tic reduction and utilization rates of behavioral treatment remain relatively low. Patient associations point to an urgent need for easy-to-undergo treatments that focus both on tic reduction and improvement of quality of life. To enhance treatment outcome and overcome treatment barriers, this pilot study's aim was to investigate the feasibility and preliminary results of a brief, intensive group-based treatment. Tackle your Tics is a 4-day intensive and comprehensive group-based program for children and adolescents (9-17 years) with a tic disorder, consisting of exposure and response prevention (ERP) treatment and additional supporting components, such as coping strategies, relaxing activities and parent support. Assessments were performed pre- and post-treatment and at 2 months follow-up, to test outcomes on tic severity and quality of life, and explore premonitory urges, emotional and behavioral functioning and treatment satisfaction (N = 14, of whom 13 completed the treatment). Parents and children rated this treatment positive on a treatment satisfaction questionnaire. On tic severity (Yale Global Tic Severity Scale) and quality of life (Gilles de la Tourette Syndrome Quality of Life Scale for children and adolescents), improvements between pre-treatment and follow-up were found. Intensive ERP in group format is promising as a feasible treatment to improve both tic severity as well as quality of life. Larger controlled trials are needed to establish its effectiveness.

The Efficacy of Acupuncture on Tic Disorders in Children: A Retrospective and Propensity Score-Matched Study

Background : Acupuncture has been considered as a complementary or alternative therapy for children with tic disorders (TD), but its efficacy remains largely unknown. This study retrospectively examined the efficacy of acupuncture treatment for TD in children over the course of 12 weeks. Methods: Data were collected from Traditional Chinese Medicine clinics in a public pediatric hospital in Shanghai between June 2020 and March 2021. A total of 250 patients with TD were included in the study, with 122 patients exposed to acupuncture therapy combined with conventional treatment (observation group), and 128 patients exposed to conventional treatment alone (control group). Propensity score matching analyses were used to balance baseline characteristics, resulting in 78 matched patients for each group. Reductions in the Yale Global Tic Severity Scale (YGTSS) total score were analyzed in the two groups after 12 weeks of treatment. Results: The two groups reached equilibrium in terms of baseline demographic characteristics and YGTSS total score after the propensity score matching (P > 0.05). Compared to the control group, the reduction in the YGTSS total score after 12 weeks of treatment was greater for the observation group (OR = 2.94, 95% CI: 1.03, 8.39, P = 0.04), and this association was stronger for patients who had significant vocal tics (β = 0.29, 95% CI: 0.88, 2.68, P = 0.001). The clinical efficacy for the observation group was significantly better than the control group. Conclusions: We provided preliminary evidence supporting the therapeutic effect of acupuncture for TD in children. Hence, our findings indicate that acupuncture could be an adjuvant treatment efficacious for TD in children, especially for vocal tics.

Challenges in the Diagnosis and Assessment in Patients with Tourette Syndrome and Comorbid Obsessive-Compulsive Disorder

Tourette syndrome (TS) is characterized by the presence of vocal and motor tics with an onset in childhood. In almost 80% of patients psychiatric comorbidities coexist, particularly, attention deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD) or behavior (OCB), depression, anxiety, rage attacks, and self-injurious behaviour (SIB). In this review, we discuss current state of the art regarding diagnosis and assessment of tics and OCD in patients with TS as well as challenges related to differential diagnosis between tics and OCD-related phenomena based on a systematic literature search. While in most cases clinical symptoms can be easily classified as either tics or OCB/OCD, some phenomena lay on the frontier between tics and compulsions/obsessions. For example, compulsions may resemble tics and, vice versa, sequences of motor tics may be misdiagnosed as compulsions. Accordingly, the terms "compulsive tics" and "cognitive tics" have been introduced. The most common and typical OCD symptom in patients with TS are "just right" phenomena, which also may show an overlap with tics, since patients may perform tics repeatedly until this feeling is achieved. Similarly, repetitive behaviors in patients with TS may manifest in a more "tic-like" or a more "OCD-like" type. Furthermore, SIB shows similarities with both tics and OCD. Until today, it is unclear how to classify this symptom best, although from most recent research a closer relationship between SIB and tics is suggested. In this review, in addition, we illustrate differences of the clinical spectrum of OCD in patients with TS compared to those with "pure OCD" without tics. To assess tics, the revised version of the Yale Global Tic Severity Scale (YGTSS-R) should be used, while for the assessment of OCD, the Yale Brown Obsessive Compulsive Disorder Scale (Y-BOCS) is recommended. Finally, we briefly summarize treatment strategies for tics and OCB/OCD in patients with TS.

Defining tic severity and tic impairment in Tourette Disorder

OBJECTIVE

Treatment guidelines for Tourette's Disorder (TD) are based on patients' degree of tic severity and impairment. However, clear benchmarks for determining tic severity and impairment have not been established. This study examined benchmarks of tic severity and tic impairment using the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impression of Severity (CGI-S).

METHOD

Individuals with TD or another Tic Disorder (N = 519) recruited across nine sites were administered a diagnostic interview, the YGTSS, and the CGI-S. Correlations and trend analyses contrasted YGTSS scores across CGI-S ratings. A logistic regression model examined predictive benchmarks for tic severity, tic impairment, and global severity. Model classifications were compared against CGI-S ratings, and agreement was examined using kappa.

RESULTS

Spearman correlations between the CGI-S and YGTSS scores ranged from 0.54 to 0.63 (p < 0.001). Greater CGI-S ratings were associated with a linear stepwise increase in YGTSS Total Tic scores, Impairment scores, and Global Severity scores. Despite moderate-to-strong associations (ρ = 0.45-0.56, p < 0.001) between the CGI-S and predictive logistical regression models, only fair agreement was achieved when applying classification benchmarks (κ = 0.21-0.32, p < 0.001).

CONCLUSIONS

CGI-S ratings are useful to characterize benchmarks for tic severity, tic impairment, and global severity on the YGTSS. Logistic regression model benchmarks had only fair agreement with the CGI-S and underscore the heterogeneity of TD symptoms. Collectively, findings offer guidance on the delineation of tic severity categorizations to apply evidence-based treatment recommendations.