Prevalence and clinical correlates of explosive outbursts in Tourette syndrome

Prenatal Tobacco Exposure and Behavioral Disorders in Children and Adolescents: Systematic Review and Meta-Analysis

Prenatal tobacco exposure has been implicated in increased risk of the development of behavioral disorders in children and adolescents. The purpose of the current study was to systematically examine the association between prenatal tobacco exposure and diagnoses of Attention Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder in childhood and adolescence. We searched Medline, Psychinfo, ERIC, Proquest, Academic Search Complete, PsychArticles, Psychology and Behavioral Sciences Collection, Web of Science, CINAHL Plus, and Google Scholar databases through October 2022. The authors screened studies and extracted data independently in duplicate. Ten clinical studies examining diagnoses of Attention Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder between the ages of 4 and 18 years old were included. There was insufficient evidence to synthesize outcomes related to Conduct Disorder and Oppositional Defiant Disorder. The meta-analysis found a significant effect of prenatal tobacco exposure in increasing the likelihood of an Attention Deficit/Hyperactivity Disorder diagnosis in childhood and adolescence. Implications for future research are discussed.

Sex Differences in Youth with Chronic Tic Disorder and Tourette Syndrome: Evaluation of Tic Severity, Psychological Profiles, and Quality of Life

Background: Tourette syndrome (TS) and Chronic Tic Disorder (CT) are neurodevelopmental conditions involving motor and/or phonic tics. Youth with tics may encounter feelings of isolation, diminished self-esteem and quality of life, and academic difficulties. A growing body of scientific literature suggests sex differences in youth with tics, but findings have been mixed so far. Because symptom severity peaks around puberty, understanding sex differences in tic manifestations and associated symptoms during this critical period is essential. Therefore, we aimed to assess sex differences related to tic symptoms, action planning styles, quality of life, and externalizing/internalizing symptoms in youth with tics. Methods: Our sample consisted of 66 youths with tics (19 girls) aged 7-14 (mean = 10 years). Youths were assessed with clinical interviews, as well as self- and parent-reported inventories evaluating tic symptoms, psychological profiles, and quality of life. Results: While no differences in tic symptoms were found, girls exhibited lower functional inflexibility, reduced overall functional planning effectiveness, and higher impairment in the psychological well-being subscale than boys. Additionally, girls had reduced general life satisfaction and social self-esteem. Boys reported more explosive outbursts, higher levels of hyperactivity, and more difficulties with self-concept. Conclusions: Our analyses suggested differences in several manifestations associated with tics. This introduces new perspectives that refine our understanding of sex differences. A better understanding of sex differences in tic disorders may eventually improve outcomes for all individuals living with these conditions.

Tics emergencies and malignant tourette syndrome: Assessment and management

Tourette syndrome (TS) is a complex neurodevelopmental disorder characterized by the presence of tics, frequently accompanied by a variety of neuropsychiatric comorbidities. A subset of patients with TS present with severe and disabling symptoms, requiring prompt therapeutic intervention. Some of these manifestations may result in medical emergencies when severe motor or phonic tics lead to damage of anatomical structures closely related to the tic. Examples include myelopathy or radiculopathy following severe neck ("whiplash") jerks or a variety of self-inflicted injuries. In addition to self-aggression or, less commonly, allo-aggression, some patients exhibit highly inappropriate behavior, suicidal tendencies, and rage attacks which increase the burden of the disease and are important components of "malignant TS". This subset of TS is frequently associated with comorbid obsessive-compulsive disorder. Therapeutic measures include intensive behavioral therapy, optimization of oral pharmacotherapy, botulinum toxin injections, and deep brain stimulation.

Tourette syndrome and other tic disorders of childhood

Tics are repetitive, patterned, and nonrhythmic movements or vocalizations/audible sounds that are misplaced in context. Phenomenology and characteristics of tics (e.g., premonitory urge, suppressibility) differentiate them from compulsions, stereotypies, functional tic-like behaviors, and other types of hyperkinetic movement disorders. With a prevalence of approximately 1% in school-aged boys, Tourette syndrome (TS) is considered a common childhood-onset neurodevelopmental disorder, defined by the combination of at least two motor tics and at least one phonic tic lasting more than 1 year. TS is a highly heritable disorder, with a wide spectrum of severity. In some individuals, tics can cause pain, distress, functional impairment, or stigmatization. About 90% of individuals with TS have at least one mental health comorbidity (attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, anxiety/depressive disorders). These comorbidities significantly impact patients' quality of life and must therefore be screened and managed accordingly in this population. Treatment of tics is based on behavioral therapies targeting tics (habit reversal training included in the comprehensive behavioral intervention for tics, and exposure and response prevention for tics), in association with medication if needed (e.g., alpha-2-agonists, second-generation antipsychotics). Deep brain stimulation is considered an experimental option in the most severe, treatment-resistant patients. In adulthood, less than 25% of individuals still have moderate or severe tics.

Co-Occurrence of Tic Disorders and Attention-Deficit/Hyperactivity Disorder-Does It Reflect a Common Neurobiological Background?

BACKGROUND

The co-existence of tic disorders and attention-deficit/hyperactivity disorder (TD + ADHD) has proven to be highly important in daily clinical practice. The factor ADHD is not only associated with further comorbidities, but also has a long-term negative psychosocial effect, while the factor TD is usually less disturbing for the major part of the patients. It remains unclear how far this is related to a different neurobiological background of the associated disorders or whether TD + ADHD reflects a common one.

OBJECTIVE

This review provides an update on the neurobiological background of TD + ADHD in order to better understand and treat this clinical problem, while clarifying whether an additive model of TD + ADHD holds true and should be used as a basis for further clinical recommendations.

METHOD

A comprehensive research of the literature was conducted and analyzed, including existing clinical guidelines for both TD and ADHD. Besides genetical and environmental risk factors, brain structure and functions, neurophysiological processes and neurotransmitter systems were reviewed.

RESULTS

Only a limited number of empirical studies on the neurobiological background of TD and ADHD have taken the peculiarity of co-existing TD + ADHD into consideration, and even less studies have used a 2 × 2 factorial design in order to disentangle the impact/effects of the factors of TD versus those of ADHD. Nevertheless, the assumption that TD + ADHD can best be seen as an additive model at all levels of investigation was strengthened, although some overlap of more general, disorder non-specific aspects seem to exist.

CONCLUSION

Beyond stress-related transdiagnostic aspects, separate specific disturbances in certain neuronal circuits may lead to disorder-related symptoms inducing TD + ADHD in an additive way. Hence, within a classificatory categorical framework, the dimensional aspects of multilevel diagnostic-profiling seem to be a helpful precondition for personalized decisions on counselling and disorder-specific treatment in TD + ADHD.

Structural hyperconnectivity of the subthalamic area with limbic cortices underpins anxiety and impulsivity in Tourette syndrome

Tourette syndrome (TS) is a neurodevelopmental disorder characterized by motor and vocal tics, which is often associated with psychiatric comorbidities. Dysfunction of basal ganglia pathways might account for the wide spectrum of symptoms in TS patients. Although psychiatric symptoms may be related to limbic networks, the specific contribution of different limbic structures remains unclear. We used tractography to investigate cortical connectivity with the striatal area (caudate, putamen, core and shell of the nucleus accumbens), the subthalamic nucleus (STN), and the adjacent medial subthalamic region (MSR) in 58 TS patients and 35 healthy volunteers. 82% of TS patients showed psychiatric comorbidities, with significantly higher levels of anxiety and impulsivity compared to controls. Tractography analysis revealed significantly increased limbic cortical connectivity of the left MSR with the entorhinal (BA34), insular (BA48), and temporal (BA38) cortices in TS patients compared to controls. Furthermore, we found that left insular-STN connectivity was positively correlated with impulsivity scores for all subjects and with anxiety scores for all subjects, particularly for TS. Our study highlights a heterogenous modification of limbic structure connectivity in TS, with specific abnormalities found for the subthalamic area. Abnormal connectivity with the insular cortex might underpin the higher level of impulsivity and anxiety observed in TS.

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.

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.

Immunity and Gilles de la Tourette syndrome: A systematic review and meta-analysis of evidence for immune implications in Tourette syndrome

BACKGROUND AND PURPOSE

The neurobiology of Gilles de la Tourette syndrome (GTS) is known to involve corticostriatal loops possibly under genetic control. Less is known about possible environmental triggers of GTS. Specifically, immune-related events following possible environmental inducers have been evoked, but important controversies still exist. In this systematic review and meta-analysis, we looked for evidence in favor of such possibilities.

METHODS

We performed a systematic review and meta-analysis of all immunological data in PubMed.

RESULTS

We found large discrepancies concerning immune dysfunctions in GTS, and meta-analyzing cytokines data did not allow us to conclude there is an involvement of specific cytokines in GTS neurobiology. When looking specifically at pediatric autoimmune neuropsychiatric disorder associated with streptococcus/pediatric acute onset neuropsychiatric syndrome, we found some important evidence of a possible infectious involvement but in a limited number of studies. Our meta-analysis found an increased level of anti-streptolysin O antibodies in GTS patients, but the level of anti-DNase B antibodies was not increased.

CONCLUSIONS

Too many questions still exist to allow us to definitively reach the conclusion that there is an infectious and immunological etiology in GTS. Much work is still needed to elucidate the possible role of immunology in GTS neurobiology and to favor immunological treatment rather than classical treatment.

An observational study of emotion regulation in children with Tourette syndrome

BACKGROUND

Explosive outbursts occur in 25%-70% of children with Tourette syndrome (TS) and may cause more distress than the tics themselves. Previous studies have indicated that a comorbid diagnosis of attention-deficit/hyperactivity disorder (ADHD) is associated with emotional dysregulation in TS; however, this relationship has almost exclusively been studied using parent-reported questionnaires.

METHODS

We examined emotion regulation (ER) with an observational measure in 150 medication-naïve children aged 7-12 allocated to four groups: Forty-nine children with TS, 23 children with ADHD, 16 children with TS + ADHD, and 62 typically developing controls. We assessed participants' ER ability, as well as parent-child interactions in the context of a complex puzzle task, and coded the observed behavior with the Tangram Emotion Coding Manual (TEC-M). We examined group differences in ER, as well as associations between ER and severity of symptoms pertaining to TS and ADHD.

RESULTS

Children with TS did not differ from controls in their ER ability. However, children with ADHD and TS + ADHD had more problems with ER than those with TS only and controls. Finally, parents of children with ADHD displayed more tension during the experimental task. ER ability was not associated with tic severity nor premonitory urges; however, better ER ability was associated with less severe symptoms of ADHD.

CONCLUSIONS

This study is the first to evaluate ER with an observational, clinician-rated measure in a controlled social setting in children with TS. Our findings support earlier questionnaire-based studies by showing impaired ER in children with TS + ADHD, but not in children with TS without comorbidity. These findings inform our understanding of the phenomenology of emotional dysregulation in TS and the role of comorbid disorders.

Aggression Toward Others Misdiagnosed as Primary Tics

Background

Tics describe a wide range of sudden and repetitive behaviors. Their multifaceted clinical features may resemble other explosive behaviors, including repetitive episodes of aggression toward others (allo-aggression) reported by subjects without tics. Here, we document 3 exemplary cases that help disentangle allo-aggressive behaviors from tics.

Cases

We report 3 cases who presented with an array of complex repetitive behaviors, most notably allo-aggression (eg, sudden kicking, hitting, slapping and biting others, or pushing someone off a bike), which were misdiagnosed as primary tics. In all cases, additional symptoms, such as blackouts, feeling of being controlled by different personalities, or being empowered by repetitive behaviors, and examination pointed toward different neuropsychiatric diagnoses.

Conclusions

Repetitive allo-aggressive behaviors are not part of the range of motor manifestations of tics. This observation not only has important medico-legal implications but is also relevant for the overall perception of Tourette syndrome and other primary tic disorders.

Language evolution: examining the link between cross-modality and aggression through the lens of disorders

We demonstrate how two linguistic phenomena, figurative language (implicating cross-modality) and derogatory language (implicating aggression), both demand a precise degree of (dis)inhibition in the same cortico-subcortical brain circuits, in particular cortico-striatal networks, whose connectivity has been significantly enhanced in recent evolution. We examine four cognitive disorders/conditions that exhibit abnormal patterns of (dis)inhibition in these networks: schizophrenia (SZ), autism spectrum disorder (ASD), synaesthesia and Tourette's syndrome (TS), with the goal of understanding why the two phenomena altered reactive aggression and altered cross-modality cluster together in these disorders. Our proposal is that enhanced cross-modality (necessary to support language, in particular metaphoricity) was a result, partly a side-effect, of self-domestication (SD). SD targeted the taming of reactive aggression, but reactive impulses are controlled by the same cortico-subcortical networks that are implicated in cross-modality. We further add that this biological process of SD did not act alone, but was engaged in an intense feedback loop with the cultural emergence of early forms of language/grammar, whose high degree of raw metaphoricity and verbal aggression also contributed to increased brain connectivity and cortical control. Consequently, in conjunction with linguistic expressions serving as approximations/'fossils' of the earliest stages of language, these cognitive disorders/conditions serve as confident proxies of brain changes in language evolution, helping us reconstruct certain crucial aspects of early prehistoric languages and cognition, as well as shed new light on the nature of the disorders. This article is part of the theme issue 'Reconstructing prehistoric languages'.

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.

Serious Transport Accidents in Tourette Syndrome or Chronic Tic Disorder

Background

It is unknown whether individuals with tic disorders are at increased risk for serious transport accidents.

Objectives

The aim of this study was to investigate the risk for injuries or death caused by transport and motor vehicle accidents in individuals with Tourette syndrome or chronic tic disorder.

Methods

This population‐based, sibling‐controlled cohort study included all individuals aged ≥18 years living in Sweden between 1997 and 2013 (N = 6,127,290). A total of 3449 individuals had a registered diagnosis of Tourette syndrome or chronic tic disorder in the Swedish National Patient Register. We also identified 2191 families with full siblings discordant for tic disorders. Cox proportional hazards regression modeling was used to estimate the risk for injuries or deaths as a result of transport accidents in individuals with a lifetime diagnosis of Tourette syndrome or chronic tic disorder compared with unexposed individuals and siblings.

Results

Individuals with tic disorders had a higher risk for transport injuries or death compared with the general population (adjusted hazard ratio, 1.50 [95% confidence interval: 1.33–1.69]) and their unaffected siblings (adjusted hazard ratio, 1.41 [95% confidence interval: 1.18–1.68]). The risks were similar across sexes. The exclusion of most psychiatric comorbidities did not alter the magnitude of the estimates. However, the risks were no longer significant after exclusion of individuals with comorbid attention deficit hyperactivity disorder.

Conclusions

The marginally increased risk for serious transport accidents in tic disorders is mainly driven by attention deficit hyperactivity disorder comorbidity. Improved detection and management of attention deficit hyperactivity disorder symptoms in this patient group are warranted. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

Reappraisal is an effective emotion regulation strategy in children with Tourette syndrome and ADHD

BACKGROUND AND OBJECTIVES

Difficulties in emotion regulation (ER) have been associated with several psychiatric disorders, emphasizing a need for a greater understanding of the concept and its associations with disruptive behavior. We aimed to study the ER strategy of cognitive reappraisal with an experimental test to increase our knowledge of emotional processes in child psychopathology.

METHODS

In the present study, we examined emotional reactivity and cognitive reappraisal with a computer task in 160 medication-naïve children aged 8-12 comprising four groups: Fifty-eight children with Tourette syndrome (TS), 26 children with attention-deficit/hyperactivity disorder (ADHD), 19 children with TS and ADHD, and 57 typically developing controls.

RESULTS

The use of cognitive reappraisal reduced negative affect across all participants and the ability to reappraise was positively correlated with age, whereas reactivity was not. Overall, groups did not differ in reactivity or regulation success. Looking at specific differences within groups, however, only the ADHD group did not significantly decrease negative affect when reappraising. Finally, the use of strategies considered to be efficacious was correlated with regulation success, whereas the use of a less adaptive strategy related to suppression was associated with reactivity, but not regulation of emotions.

LIMITATIONS

The study was limited by small, clinical contrast groups and a lack of blinding to diagnostic status in the coding of verbal strategies employed during the task.

CONCLUSIONS

Cognitive reappraisal appears to be a beneficial ER strategy for children regardless of diagnostic status. Our findings indicate that children can learn and employ an adaptive ER strategy when instructed in the technique, even in the presence of attention problems, which is highly relevant to therapeutic approaches to dysregulated behavior.

Structural and functional abnormalities within sensori-motor and limbic networks underpin intermittent explosive symptoms in Tourette disorder

BACKGROUND

Intermittent explosive outbursts (IEO), manifesting as sudden episodes of verbal or physical aggression, are frequently present in patients with Tourette disorder (TD) and considered as one of the most disabling symptoms by patients and families. The neuronal correlates of these behaviours are poorly understood, and this was the primary objective of the present study.

METHODS

We assessed the presence of IEO in 55 patients with TD and then compared the subgroup of the patients with IEO to those without these manifestations using a multimodal neuroimaging approach.

RESULTS

47% of TD patients presented IEO, which was frequently associated with attention deficit hyperactivity disorder (ADHD). TD patients (without ADHD) with IEO compared to TD without IEO, showed structural changes in the right supplementary motor area as well as in the right hippocampus (increased fractional anisotropy), and in the left orbitofrontal cortex (decreased mean diffusivity). Using these three nodes as seeds for resting state functional connectivity, we showed a lower connectivity within the sensori-motor cortico-basal ganglia network, and an altered connectivity pattern among the orbito-frontal cortex, amygdala and hippocampus.

CONCLUSIONS

Overall, our results indicate that TD with IEO is associated with brain dysfunction related to a less efficient top-down control on action selection, and impairments related to emotional regulation, impulse control and aggressive behaviours.

Clinical Features of Tourette Syndrome

Tourette syndrome is a multifaceted disorder characterized by multiple motor and at least one vocal tics that start in childhood, persist for at least 1 year, and cannot be attributed to another medical condition or exposure to medications/drugs. Clinical diagnostic criteria are available, and identification of tics is typically straightforward based on characteristic appearance and features. Diagnostic uncertainty can rarely arise in cases of mild tics, atypical features, certain psychiatric comorbidities, and other non-tic movement disorders. Comorbid psychopathology, including attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive behaviors/obsessive-compulsive disorder, affects the majority of patients and is correlated with disease severity and the presence of additional psychiatric behaviors. The severity of tics often improves after adolescence, whereas psychiatric symptoms typically persist. The subset of patients in whom tics persist into adulthood experience higher rates of anxiety, and lower self-esteem, socioeconomic status, and quality of life; the relative contribution of motor tics and psychopathology is not fully understood. This article summarizes the clinical features of Tourette syndrome, including major diagnostic criteria, unique features of tics, and key aspects that differentiate tics from common mimics and chameleons. Comorbid psychiatric conditions and their impact on phenotype and quality of life are described. Finally, current understanding of the natural history is summarized, including limited research in adults with Tourette syndrome.

Current Status, Diagnosis, and Treatment Recommendation for Tic Disorders in China

Tic disorders (TD) are a group neuropsychiatric disorders with childhood onset characterized by tics, i.e. repetitive, sudden, and involuntary movements or vocalizations; and Tourette syndrome (TS) is the most severe form of TD. Their clinical manifestations are diverse; and are often associated with various psychopathological and/or behavioral comorbidities, including attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, depression, and sleep disorders. Individual severity and response to treatment are highly variable, and there are some refractory cases, which are less responsive to conventional TD treatment. TD/TS are also common in the Chinese pediatric population. To help improve the understanding of TD for pediatricians and other health professionals, and to improve its diagnosis and treatment in China, the Chinese Child Neurology Society (CCNS) has developed an Expert Consensus on Diagnosis and Treatment of TD in China, which is based on our clinical experience and the availability therapeutic avenues. It is focused on clinical diagnosis and evaluation of TD and its comorbidities, psychological and educational intervention, nonpharmacological therapy, pharmacological treatment, including traditional Chinese medicine and acupuncture, as well as prognosis in children with TD in China. A summary of the current status of TD and up-to-date diagnosis and treatment recommendations for TD in China is presented here.

From Physical Aggression to Verbal Behavior: Language Evolution and Self-Domestication Feedback Loop

We propose that human self-domestication favored the emergence of a less aggressive phenotype in our species, more precisely phenotype prone to replace (reactive) physical aggression with verbal aggression. In turn, the (gradual) transition to verbal aggression and to more sophisticated forms of verbal behavior favored self-domestication, with the two processes engaged in a mutually reinforcing feedback loop, considering that verbal behavior entails not only less violence and better survival but also more opportunities to interact longer and socialize with more conspecifics, ultimately enabling the emergence of more complex forms of language. Whereas in the case of self-domestication, sexual selection has been proposed to work against physical aggression traits, in the case of verbal insult, the selection has been proposed to work in favor of verbal aggression. The tension between these two seemingly opposing forces gets resolved/alleviated by a tendency to replace physical aggression with verbal aggression and with verbal behavior more generally. This also helps solve the paradox of the Self-Domestication Hypothesis regarding aggression, more precisely why aggression in humans has been reduced only when it comes to reactive aggression, but not when it comes to proactive aggression, the latter exhibiting an increase in the advent of modern language. We postulate that this feedback loop was particularly important during the time period arguably between 200 and 50 kya, when humans were not fully modern, neither in terms of their skull/brain morphology and their behavior/culture nor in terms of their self-domestication. The novelty of our approach lies in (1) giving an active role to early forms of language in interacting with self-domestication processes; (2) providing specific linguistic details and functions of this early stage of grammar (including insult and humor); (3) supplying neurobiological, ontogenetic, and clinical evidence of a link between (reactive) aggression and (reactive) verbal behavior; (4) identifying proxies of the earlier stages in evolution among cognitive disorders; and (5) identifying specific points of contact and mutual reinforcement between these two processes (self-domestication and early language evolution), including reduction in physical aggression and stress/tension, as well as sexual selection.

The Rage Attack Questionnaire-Revised (RAQ-R): Assessing Rage Attacks in Adults With Tourette Syndrome

INTRODUCTION

Although defined by the presence of tics, most patients with Gilles de la Tourette syndrome (TS) also suffer from different psychiatric disorders. While much is known about clinical characteristics of comorbidities such as attention deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), depression, and anxiety disorders, only very little is known about rage attacks. Most of this data is based on small studies in children. Until today no larger studies have been performed in adults with TS-most likely because of the lack of validated instruments. The aim of this study was to develop a new assessment and investigate rage attacks in a large sample of adults with TS and healthy individuals.

MATERIALS AND METHODS

Based on a parent questionnaire for children with TS, we generated 27 items for a revised version of a rage attack questionnaire (RAQ-R) and tested factor structure, internal consistency, as well as convergent and discriminant validity. We used an online survey and included 127 patients with TS and 645 control subjects. In addition to the RAQ-R, we used several other self-assessments to measure tic severity, quality of life, as well as several psychiatric symptoms including ADHD, OCD, depression, anxiety, and impulsivity.

RESULTS

Based on expert option and statistical analyses [including item-total correlation, skewness, inter-item correlation, and principal component analysis (PCA)], we performed an item reduction resulting in a final, 22-items version of the RAQ-R (range, 0-66). Investigating internal consistency, discriminant validity, test reliability, and factor structure, the RAQ-R demonstrated good to excellent quality criteria. As assessed by RAQ-R, rage attacks were significantly more common in patients with TS compared to controls (p < 0.001). Rage attacks could be clearly differentiated from the phenomenon of impulsivity. Although rage attacks occurred more often in individuals with ADHD, they were also found in patients with "TS only", independently from comorbid ADHD, impulsivity, and OCD. Rage attacks were found to significantly influence patients' quality of life.

CONCLUSIONS

Thus, from our data based on a large sample it is suggested that rage attacks represent a discrete comorbidity in adults with TS.

Cognitive Behavioral Therapy for Anger and Aggression in a Child With Tourette’s Syndrome

Tourette syndrome (TS) is a neurodevelopmental disorder that is characterized by vocal and motor tics. Children with TS often also exhibit disruptive behaviors including sudden anger outbursts accompanied by verbal and physical aggression. This case study presents cognitive behavioral therapy (CBT) treatment of anger and aggression in a 9-year-old girl with TS, co-occurring generalized anxiety disorder (GAD), and oppositional defiant disorder (ODD). At initial assessment, tics were well-managed and disruptive behavior concerns, including near-daily tantrums lasting 20 min to 1 hr, were primary clinical concerns. The child and her mother received 12 weekly sessions of CBT for anger and aggression, with select supplements and modifications that related to the context of TS. Posttreatment assessment indicated a significant decrease in noncompliance, anger outbursts, and aggressive behavior. CBT for anger and aggression can be a useful treatment for the disruptive behaviors that often co-occur with TS.

Major and minor life events, personality and psychopathology in children with tourette syndrome

Environmental, psychological, and biological interactions underlie many psychopathologies. Tourette's Syndrome (TS) has an obvious biological substrate but environmental factors and personality play substantial roles in its expression. We aimed to study the interrelationships between stressful life events, personality traits, tics, and comorbid disorders in children with TS. To this end, 132 children with TS and 49 healthy controls were recruited for the study. Major life events in the 12-months prior to testing and minor life events in the month prior to testing were retrospectively assessed using the Life Experiences Survey (LES) and the Brief Adolescent Life Events Scale (BALES), respectively. Personality was assessed with the Junior Temperament and Character Inventory (JTCI). Tics, obsessive compulsive symptoms, attention deficit and hyperactivity symptoms, anxiety, depression and aggression were assessed by self-report questionnaires and semi-structured interviews. We found that major life events correlated with the severity of tics expression and complexity, and comorbid psychopathology. Minor life events correlated with more severe symptomatology. High levels of harm avoidance were related to more obsessions, anxiety, and depression whereas high levels of self-directedness were protective. To conclude, TS expression in childhood should be understood as the result of an interaction between biological, personality and environmental factors.

A Review of the Neuropsychological Dimensions of Tourette Syndrome

Neurocognitive functioning in Tourette syndrome (TS) has been the subject of intensive research in the past 30 years. A variety of impairments, presumably related to frontal and frontostriatal dysfunctions, have been observed. These impairments were found in various domains, such as attention, memory, executive functions, language, motor and visuomotor functions, among others. In line with contemporary research, other neurocognitive domains have recently been explored in TS, bringing evidence of altered social reasoning, for instance. Therefore, the aims of this review are to give an overview of the neuropsychological dimensions of TS, to report how neuropsychological functions evolve from childhood to adulthood, and to explain how various confounding factors can affect TS patients' performance in neuropsychological tasks. Finally, an important contribution of this review is to show how recent research has confirmed or changed our beliefs about neuropsychological functioning in TS.

The puzzling question of inhibitory control in Tourette syndrome: A meta-analysis

Tourette syndrome (TS) is a neuropsychiatric disorder involving motor and phonic tics. Inhibitory control is a key issue in TS, and many disruptive or impulsive behaviors might arise from inhibitory deficits. However, conflicting findings regarding TS patients' inhibitory performance in neuropsychological tasks have been reported throughout the literature. Therefore, this meta-analysis aimed to evaluate inhibitory control through neuropsychological tasks, and to analyze the factors modulating inhibitory deficits. To this end, a literature search was performed through MEDLINE and PsycINFO, to retrieve studies including neuropsychological tasks that assessed inhibitory control in TS patients. Of the 4020 studies identified, 61 were included in the meta-analysis, for a total of 1717 TS patients. Our analyses revealed a small to medium effect in favor of inhibitory deficits in TS patients. This effect was larger in TS+ADHD patients, but pure TS patients also showed some inhibitory deficits. Therefore, deficits in inhibitory control seem to be an inherent component of TS, and are exacerbated when ADHD is concomitant.

A preliminary examination of self-concept in older adolescents and young adults with Gilles de la Tourette syndrome

INTRODUCTION

Gilles de la Tourette syndrome (GTS) is a childhood-onset neuropsychiatric disorder characterised by multiple tics and often associated with behavioural problems. Although there is evidence of significantly reduced self-esteem in children and adolescents with GTS, little is known about perceived self-concept and its clinical determinants at the transition age between adolescence and adulthood. We therefore set out to investigate self-concept in a clinical sample of young patients with GTS at this crucial age for personal development.

METHODS

In addition to standard demographic and clinical data, we collected self-ratings using a standardised battery of psychometric instruments, as well as the Multidimensional Self Concept Scale, a comprehensive questionnaire developed to assess self-concept in subjects aged 9- to 19 years, tapping into the social, competence, affect, academic, family, and physical domains.

RESULTS

We found that patients diagnosed with at least one co-morbid psychiatric disorder ("GTS-plus" phenotype) reported significantly lower self-concept than patients with "pure GTS", whereas tic-related variables had no impact on self-concept. Anxiety symptoms were the main determinants of self-concept, especially trait anxiety with regard to social and affective domains. Affective symptoms could also have a negative impact on the physical, affective, competence, and social domains of self-concept.

CONCLUSION

Routine screening for anxiety and affective symptoms should be recommended in all patients with GTS seen at transition clinics from paediatric to adult care, in order to implement effective treatment interventions whenever possible.

An initial study of family accommodation in children and adolescents with chronic tic disorders

This initial study examined the nature, incidence, and clinical correlates of family accommodation in youth with tic disorders, and validated a brief self-report measure of tic-related family accommodation, the Tic Family Accommodation Scale (TFAS). Seventy-five youth aged 6-18 who were diagnosed with a tic disorder and their parent completed a diagnostic clinical interview, and clinician and parent-report measures of tic severity, depressive symptoms, anxiety symptoms, behavioral problems, family accommodation and impairment. An exploratory factor analysis of the TFAS showed a two-factor structure, with good internal consistency for the Total score, Modification of Child Environment and Modification of Parent Environment subscales (α = 0.88, 0.86, and 0.81, respectively). Family accommodation was not associated with tic severity. Family accommodation was associated with increased anxiety and depressive symptoms, higher externalizing, rule breaking, aggressive behaviors and social problems, and with greater tic-related functional impairment. Anxiety and externalizing problems (but not depressive symptoms) predicted family accommodation when controlling for tic severity. Family accommodation predicted high levels of functional impairment over and above the effect of tic severity, anxiety, depression and externalizing problems. Family accommodation is a common phenomenon for youth with tic disorders, with modifications typically encompassing changes to the child and/or parent environments. Accommodation was not associated with tic severity, but was related to higher levels of anxiety, depressive symptoms, externalizing symptoms, aggression, and rule breaking behaviors. Results suggest that other emotional symptoms are more likely to drive accommodation practices than the tic symptoms per se.

The rise of moral emotions in neuropsychiatry

Clinical psychopathology has largely ignored the developments in the field of social neuroscience. The so-called moral emotions are a group of affective experiences thought to promote cooperation, group cohesion, and reorganization. In this review, we: (i) briefly describe a provisional taxonomy of a limited set of moral emotions and their neural underpinnings; and (ii) discuss how disgust, guilt, anger/indignation, and shame/embarrassment can be conceptualized as key affective experiences in different neuropsychiatric disorders. Based on a concise review of the literature linking moral emotions, psychopathology, and neuropsychiatry, we have devised a simple and preliminary scheme where we conjecture how specific moral emotions can be implicated in some categories of DSM-5 diagnoses, potentially helping to bridge psychopathology and neurobiologically plausible variables, in line with the Research Domain Criteria initiative. We hope this stimulates new empirical work exploring how moral emotional changes and their underlying neurobiology can help elucidating the neural underpinnings of mental disorders.

The premonitory urge revisited: An individualized premonitory urge for tics scale

BACKGROUND

Premonitory urge ratings have advanced our understanding of urge phenomenology among individuals with tic disorders (TD). However, these ratings have been limited by their reliance on a single global dimension of urge severity. This study examined the psychometric properties of a novel scale called the Individualized Premonitory Urge for Tics Scale (I-PUTS) that assesses urge severity across multiple dimensions (number, frequency, and intensity).

METHOD

Seventy-five youth with a TD and their parents participated. Clinicians assessed youth's tic severity, depression severity, rages, and premonitory urges. Parents completed ratings of youth's anxiety, affect lability, and general psychopathology. Youth completed self-report ratings of anxiety, urge severity, and distress tolerance.

RESULTS

The I-PUTS identified that youth experienced an average of three distinct urges, but had an average of seven tics over the past week. Urges were primarily localized in the head/face, neck/throat, and arm regions. All I-PUTS dimensions exhibited excellent inter-rater reliability. The I-PUTS dimensions exhibited good convergent validity with global urge ratings and tic severity, and appropriate divergent validity from other clinical constructs. Youth who exhibited discrepant reports between clinician-administered and self-report urge ratings had less anxiety and tic severity, and greater inattention and externalizing problems compared to youth who exhibited good agreement.

CONCLUSIONS

The I-PUTS is a reliable and valid assessment of urge phenomena, which provides additional and complementary information to existing urge scales. It highlights the existence of multiple dimensions of urge severity, and presents particular utility when assessing urges in youth with TD who have inattention and externalizing problems.

Treatment-refractory Tourette Syndrome

Tourette Syndrome (TS) is a complex neurodevelopmental condition marked by tics and frequently associated with psychiatric comorbidities. While most cases are mild and improve with age, some are treatment-refractory. Here, we review strategies for the management of this population. We begin by examining the diagnosis of TS and routine management strategies. We then consider emerging treatments for refractory cases, including deep brain stimulation (DBS), electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and novel pharmacological approaches such as new vesicular monoamine transporter type 2 inhibitors, cannabinoids, and anti-glutamatergic drugs.

A personal 35 year perspective on Gilles de la Tourette syndrome: prevalence, phenomenology, comorbidities, and coexistent psychopathologies

This Series is a personal narrative of my experience with patients with Gilles de la Tourette syndrome and covers its definition and history since the first description in 1825. Controversy entered the prevalence debate early. Although originally considered very rare, in the 1980s, Tourette's syndrome was reported to be common. However, Tourette's syndrome has been shown to occur at a prevalence of about 0·85% to 1%. Tourette's syndrome is more common in the male population, more prominent during childhood, and usually improves, but does not disappear with age. Tourette's syndrome is considered less common in people of sub-Saharan black African, African-American, and American Hispanic ethnic origin. The phenomenology is similar worldwide, indicating a biological basis. The hallmark characteristics are multiple motor and one or more vocal/phonic tics. Other associated features include premonitory urges, a waxing and waning course, and to a much lesser degree, coprolalia. Comorbid disorders are common and are suggested to include obsessive-compulsive disorder and behaviours, attention deficit hyperactivity disorder, and autistic spectrum disorder. Coexistent psychopathologies are suggested to include depression and conduct and personality disorders. Importantly, I argue that Tourette's syndrome is not a unitary condition. Finally, I offer suggestions for future research.

The Semiology of Tics, Tourette's, and Their Associations

Gilles de la Tourette syndrome (GTS) is a prototypical neuropsychiatric disorder breaking the boundary of disciplinary dualism between neurology and psychiatry. The diagnosis of GTS is clinical and, in most cases, straightforward. Tics as a hallmark of GTS are usually easy to recognize and distinguish from other movement disorders as fragmented, repetitive, exaggerated movements resembling normal motor behavior, but appearing out of context. In complex cases, knowledge on additional characteristics and signs as, for example, tic distribution, suggestibility, voluntary tic inhibition, and presence of echo- or paliphenomena might further aid clinical diagnosis. However, although defining GTS, tics are rarely the main issue. The presence of comorbidities and coexisting psychopathologies often hampers normal development and negatively affects quality of life. Their recognition and treatment is paramount. Here, we review existing literature and provide a comprehensive update on the multifarious aspects of the movement disorder and neuropsychiatry of GTS. We also provide a list of associated movement disorders known to occur in GTS patients and discuss differential diagnoses to be considered in atypical cases. We finally comment on available treatment options.

Neuroendocrine aspects of Tourette syndrome

There is sparse evidence suggesting the participation of neuroendocrine mechanisms, mainly involving sex and stress steroid hormones, to the pathophysiology of neurodevelopmental disorders such as Tourette syndrome (TS) and obsessive-compulsive disorder (OCD). Patients with TS exhibit a sex-specific variability in gender distribution (male/female ratio=3-4/1) and in its natural history, with a severity peak in the period around puberty. The administration of exogenous androgens may worsen tics in males with TS, whereas drugs counteracting the action of testosterone might show some antitic efficacy. This suggests a higher susceptibility of patients with TS to androgen steroids. There are insufficient data on the regulation of the hypothalamic-pituitary-gonadal (HPG) axis in TS. However, preliminary evidence suggests that a subgroup of women with TS might be more sensitive to the premenstrual trough of estrogen levels. Patients with TS exhibit differences in a number of behavioral, cognitive, and anatomical traits that appear to be sex related. There is a body of evidence supporting, albeit indirectly, the hypothesis of an increased exposure to androgenic steroids during the very early phases of neural development. Animal models in rodents suggest a complex role of gonadal hormones upon the modulation of anxiety-related and stereotyped behaviors during adult life. Patients with TS exhibit an enhanced reactivity of the hypothalamic-pituitary-adrenal axis to external stressors, despite a preserved diurnal cortisol rhythm and a normal restoration of the baseline activity of the axis following the acute stress response. Preliminary evidence suggests the possible implication of oxytocin (OT) in disorders related to the TS spectrum, especially non-tic-related OCD. The injection of OT in the amygdala of rodents was shown to be able to induce hypergrooming, suggesting the possible involvement of this neuropeptide in the pathophysiology of complex, stereotyped behaviors. In contrast, there is anecdotal clinical evidence that tics improve following periods of affectionate touch and sexual intercourse.