Social cognition in Tourette's syndrome: intact theory of mind and impaired inhibitory functioning

Aberrant Functional Connectivity of the Salience Network in Adult Patients with Tic Disorders: A Resting-State fMRI Study

Tic disorders (TD) are characterized by the presence of motor and/or vocal tics. Common neurophysiological frameworks suggest dysregulations of the cortico-striatal-thalamo-cortical (CSTC) brain circuit that controls movement execution. Besides common tics, there are other "non-tic" symptoms that are primarily related to sensory perception, sensorimotor integration, attention, and social cognition. The existence of these symptoms, the sensory tic triggers, and the modifying effect of attention and cognitive control mechanisms on tics may indicate the salience network's (SN) involvement in the neurophysiology of TD. Resting-state functional MRI measurements were performed in 26 participants with TD and 25 healthy controls (HC). The group differences in resting-state functional connectivity patterns were measured based on seed-to-voxel connectivity analyses. Compared to HC, patients with TD exhibited altered connectivity between the core regions of the SN (insula, anterior cingulate cortex, and temporoparietal junction) and sensory, associative, and motor-related cortices. Furthermore, connectivity changes were observed in relation to the severity of tics in the TD group. The SN, particularly the insula, is likely to be an important site of dysregulation in TD. Our results provide evidence for large-scale neural deviations in TD beyond the CSTC pathologies. These findings may be relevant for developing treatment targets.

Social cognition in hyperkinetic movement disorders: a systematic review

Numerous lines of research indicate that our social brain involves a network of cortical and subcortical brain regions that are responsible for sensing and controlling body movements. However, it remains unclear whether movement disorders have a systematic impact on social cognition. To address this question, we conducted a systematic review examining the influence of hyperkinetic movement disorders (including Huntington disease, Tourette syndrome, dystonia, and essential tremor) on social cognition. Following the PRISMA guidelines and registering the protocol in the PROSPERO database (CRD42022327459), we analyzed 50 published studies focusing on theory of mind (ToM), social perception, and empathy. The results from these studies provide evidence of impairments in ToM and social perception in all hyperkinetic movement disorders, particularly during the recognition of negative emotions. Additionally, individuals with Huntington's Disease and Tourette syndrome exhibit empathy disorders. These findings support the functional role of subcortical structures (such as the basal ganglia and cerebellum), which are primarily responsible for movement disorders, in deficits related to social cognition.

Sensitivity and specificity of the ECAS in identifying executive function and social cognition deficits in MND

Objective: Motor neurone disease [MND] encompasses broad cognitive impairments, which are not fully captured by most screening tools. This study evaluated the specificity and sensitivity of the Edinburgh Cognitive and Behavioral ALS Screen [ECAS] in detecting impairments in executive function and social cognition. Methods: Participants (MND = 64; Healthy Controls = 45) completed the ECAS and standard neuropsychology tests of executive function and social cognition. Sensitivity and specificity of the ECAS were assessed at three levels (ALS-Specific score, executive function domain score, individual subtests: social cognition, inhibition, working memory, alternation). Results: MND patients were impaired on standard social cognition, initiation, visuomotor alternation, and verbal learning tests but not on inhibition or working memory tests, relative to controls. ECAS results revealed that the ALS-Specific score was high in specificity but low-to-moderately sensitive in identifying social cognition, inhibition, and working memory deficits, and that both sensitivity and specificity were high for identifying alternation deficits. The ECAS executive function domain score was high in specificity but poor in sensitivity for all four executive function domain subtests. The individual ECAS subtests were highly specific with good sensitivity, but the social cognition subtest lacked sensitivity. Conclusions: Impairments in social cognition may go undetected when using the ECAS as a screening tool. Thus, social cognition may need to be considered as a standalone component, distinct from the other executive functions. In addition, the test itself may need to be adjusted to encompass other aspects of social cognition that are affected in MND.Key messagesCognitive screening tools are key to detect cognitive changes in MND, with the domains most affected being executive functions, language, and social cognition.The ECAS measure, developed for MND, has good specificity but lacks sensitivity to impairments in social cognition.Clinical implications are that cognitive impairments in social cognition may not be identified in MND patients by the ECAS.Adjustment to the ECAS cognitive screening tool widely-used in MND is suggested.

The Pathophysiology of Tics; An Evolving Story

Background:

Tics, defined as quick, rapid, sudden, recurrent, non-rhythmic motor movements or vocalizations are required components of Tourette Syndrome (TS) - a complex disorder characterized by the presence of fluctuating, chronic motor and vocal tics, and the presence of co-existing neuropsychological problems. Despite many advances, the underlying pathophysiology of tics/TS remains unknown.

Objective:

To address a variety of controversies surrounding the pathophysiology of TS. More specifically: 1) the configuration of circuits likely involved; 2) the role of inhibitory influences on motor control; 3) the classification of tics as either goal-directed or habitual behaviors; 4) the potential anatomical site of origin, e.g. cortex, striatum, thalamus, cerebellum, or other(s); and 5) the role of specific neurotransmitters (dopamine, glutamate, GABA, and others) as possible mechanisms (Abstract figure).

Methods:

Existing evidence from current clinical, basic science, and animal model studies are reviewed to provide: 1) an expanded understanding of individual components and the complex integration of the Cortico-Basal Ganglia-Thalamo-Cortical (CBGTC) circuit - the pathway involved with motor control; and 2) scientific data directly addressing each of the aforementioned controversies regarding pathways, inhibition, classification, anatomy, and neurotransmitters.

Conclusion:

Until a definitive pathophysiological mechanism is identified, one functional approach is to consider that a disruption anywhere within CBGTC circuitry, or a brain region inputting to the motor circuit, can lead to an aberrant message arriving at the primary motor cortex and enabling a tic. Pharmacologic modulation may be therapeutically beneficial, even though it might not be directed toward the primary abnormality.

Controversies Surrounding the Pathophysiology of Tics

Tics are sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations (phonic productions) that are commonly present in children and are required symptoms for the diagnosis of Tourette syndrome. Despite their frequency, the underlying pathophysiology of tics/Tourette syndrome remains unknown. In this review, we discuss a variety of controversies surrounding the pathophysiology of tics, including the following: Are tics voluntary or involuntary? What is the role of the premonitory urge? Are tics due to excess excitatory or deficient inhibition? Is it time to adopt the contemporary version of the cortico-basal ganglia-thalamocortical (CBGTC) circuit? and Do we know the primary abnormal neurotransmitter in Tourette syndrome? Data from convergent clinical and animal model studies support complex interactions among the various CBGTC sites and neurotransmitters. Advances are being made; however, numerous pathophysiologic questions persist.

The psychology of Tourette disorder: Revisiting the past and moving toward a cognitively-oriented future

Tourette syndrome is a neurodevelopmental disorder characterized by chronic tics (i.e., repetitive and stereotyped movements and vocalizations) and premonitory urges (i.e., aversive sensations preceding tics that are alleviated once a tic is performed). Research supports that dysfunctional neurobiological and psychological processes interact and contribute to the development and maintenance of tics. However, psychological theories of Tourette syndrome and accompanying research have mainly focused on the emotional states (e.g., anxiety and frustration) and behavioural principles (i.e., operant conditioning) that play a role in tic exacerbation. This selective review summarizes key discoveries pertaining to the emotional and behavioural aspects of Tourette syndrome but also proposes a more comprehensive, cognitively-oriented conceptualization of the disorder. Specifically, it is proposed that maladaptive beliefs about discomfort and about one's ability to cope with discomfort underlie negative appraisals of unpleasant sensory experiences in individuals with Tourette syndrome. It is further suggested that these beliefs lead individuals to perceive premonitory urges in a catastrophic manner and thereby enhance tic frequency. Concrete research avenues to empirically examine these hypotheses are outlined and clinical implications for the field of cognitive-behaviour therapy are discussed.

Social cognition and self-other distinctions in neuropsychiatry: Insights from schizophrenia and Tourette syndrome

Impairments in social cognition may reflect dysfunction of disorder specific or disorder general mechanisms. Although cross-disorder comparison may prove insightful, few studies have compared social cognition in different neuropsychiatric disorders. Parallel investigation of schizophrenia and Tourette syndrome (TS) is encouraged by similarities including the presence of problematic social behavior, echophenomena, emotional dysregulation and dopamine dysfunction. Focusing on tests of social cognition administered in both disorders, this review aims to summarize behavioral, neurophysiological and neuroimaging findings, before exploring how these may contribute to clinical symptoms. Studies investigating social cognition (imitation, emotion recognition, and understanding of beliefs or intentions) in patients with schizophrenia or TS were identified through Web of Science and PubMed searches. Although findings indicate that social cognitive deficits are more apparent in schizophrenia, adults with TS can exhibit similar task performance to patients with paranoia. In both disorders, behavioral and neuroimaging findings raise the possibility of increased internal simulation of others' actions and emotions, in combination with a relative under-application of mentalizing. More specifically, dysfunction in neurobiological substrates such as temporo-parietal junction and inferior frontal gyrus may underlie problems with self-other distinctions in both schizophrenia and TS. Difficulties in distinguishing between actions and mental states linked to the self and other may contribute to a range of psychiatric symptoms, including emotional dysregulation, paranoia, social anhedonia and socially disruptive urges. Comparing different patient populations could therefore reveal common neuro-cognitive risk factors for the development of problematic social behaviors, in addition to markers of resilience, coping strategies and potential neuro-compensation mechanisms.

Tourette syndrome: a disorder of the social decision-making network

Tourette syndrome is a common neurodevelopmental disorder defined by characteristic involuntary movements, tics, with both motor and phonic components. Tourette syndrome is usually conceptualized as a basal ganglia disorder, with an emphasis on striatal dysfunction. While considerable evidence is consistent with these concepts, imaging data suggest diffuse functional and structural abnormalities in Tourette syndrome brain. Tourette syndrome exhibits features that are difficult to explain solely based on basal ganglia circuit dysfunctions. These features include the natural history of tic expression, with typical onset of tics around ages 5 to 7 years and exacerbation during the peri-pubertal years, marked sex disparity with higher male prevalence, and the characteristic distribution of tics. The latter are usually repetitive, somewhat stereotyped involuntary eye, facial and head movements, and phonations. A major functional role of eye, face, and head movements is social signalling. Prior work in social neuroscience identified a phylogenetically conserved network of sexually dimorphic subcortical nuclei, the Social Behaviour Network, mediating many social behaviours. Social behaviour network function is modulated developmentally by gonadal steroids and social behaviour network outputs are stereotyped sex and species specific behaviours. In 2011 O'Connell and Hofmann proposed that the social behaviour network interdigitates with the basal ganglia to form a greater network, the social decision-making network. The social decision-making network may have two functionally complementary limbs: the basal ganglia component responsible for evaluation of socially relevant stimuli and actions with the social behaviour network component responsible for the performance of social acts. Social decision-making network dysfunction can explain major features of the neurobiology of Tourette syndrome. Tourette syndrome may be a disorder of social communication resulting from developmental abnormalities at several levels of the social decision-making network. The social decision-making network dysfunction hypothesis suggests new avenues for research in Tourette syndrome and new potential therapeutic targets.

Inhibitory dysfunction contributes to some of the motor and non-motor symptoms of movement disorders and psychiatric disorders

Recently, it has been proposed that similar to goal-directed and habitual action mediated by the fronto-striatal circuits, the fronto-striato-subthalamic-pallidal-thalamo-cortical network may also mediate goal-directed and habitual (automatic) inhibition in both the motor and non-motor domains. Within this framework, some of the clinical manifestations of Parkinson's disease, dystonia, Tourette syndrome and obsessive-compulsive disorder can be considered to represent an imbalance between goal-directed and habitual action and inhibition. It is possible that surgical interventions targeting the basal ganglia nuclei, such as deep brain stimulation of the subthalamic nucleus or the internal segment of the globus pallidus, improve these disorders by restoring a functional balance between facilitation and inhibition in the fronto-striatal networks. These proposals require investigation in future studies.This article is part of the themed issue 'Movement suppression: brain mechanisms for stopping and stillness'.

Disassociation of cognitive and affective aspects of theory of mind in obsessive-compulsive disorder

Impairment in social functioning has been widely described in obsessive-compulsive disorder (OCD). However, several aspects of social cognition, such as theory of mind (ToM), have not been substantially investigated in this context. This study examined cognitive and affective ToM in 40 OCD patients and 38 age-, sex-, and education-matched healthy controls (HCs) with the computerized Yoni task and a battery of neurocognitive tests. OCD symptom severity was assessed with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Depressive and anxiety symptoms were also assessed. Compared to HCs, OCD patients performed worse on second-order affective condition trials, but not cognitive or physical condition trials, of the Yoni task; there were not group differences in any of the first-order condition domains. Second-order ToM performance of OCD patients was associated with estimated intelligence and working memory performance. After controlling for neurocognitive variables, the group difference in second-order affective condition performance remained significant. These findings indicate that the affective component of ToM may be selectively impaired in OCD patients and that the observed deficit is largely independent of other neurocognitive impairments and clinical characteristics.

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.

Cognitive flexibility and its electrophysiological correlates in Gilles de la Tourette syndrome

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Gilles de la Tourette syndrome (GTS) may involve cognitive inflexibility.

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A meta-analysis reveals GTS-related deficits on the Wisconsin Card Sorting Test.

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Card-sorting deficits are larger in children than in adults with GTS.

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Adults with GTS show electrophysiological signs of enhanced cognitive control.

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This change may underlie the normalization of cognitive flexibility in adult GTS.

Motor symptoms in Gilles de la Tourette syndrome (GTS) have been related to changes in frontostriatal brain networks. These changes may also give rise to alterations in cognitive flexibility. However, conclusive evidence for altered cognitive flexibility in patients with GTS is still lacking. Here, we meta-analyzed data from 20 neuropsychological studies that investigated cognitive flexibility in GTS using the Wisconsin Card Sorting Test (WCST). Results revealed medium-sized GTS-related performance deficits, which were significantly modulated by age: Whilst being substantial in children and adolescents with GTS, WCST deficits seem to dissolve in adult patients with GTS. This age-related normalization of WCST performance might result from the compensatory recruitment of cognitive control in adult patients with GTS. We addressed this possibility by examining neural correlates of proactive and reactive cognitive control in an event-related potential (ERP) study. We analyzed cue- and target-locked ERPs from 23 adult patients with GTS and 26 matched controls who completed a computerized version of the WCST. Compared to controls, patients with GTS showed a marked increase in parietal cue-locked P3 activity, indicating enhanced proactive cognitive control. We conclude that the additional recruitment of proactive cognitive control might ensure flexible cognitive functioning in adult patients with GTS.

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.

Comprehension of direct and indirect sarcastic remarks in children and adolescents with Tourette's syndrome

Previous research has reported that aspects of social cognition such as nonliteral language comprehension are impaired in adults with Tourette's syndrome (TS), but little is known about social cognition in children and adolescents with TS. The present study aims to evaluate a measure of sarcasm comprehension suitable for use with children and adolescents (Experiment 1), and to examine sarcasm comprehension in children and adolescents with TS-alone or TS and attention deficit hyperactivity disorder (ADHD; Experiment 2). In Experiment 1, the measure of sarcasm comprehension was found to be sensitive to differences in nonliteral language comprehension for typically-developing children aged 10 to 11 years old compared to children aged 8 to 9 years old; the older group performed significantly better on the comprehension of scenarios ending with either direct or indirect sarcastic remarks, whereas the two age groups did not differ on the comprehension of scenarios ending with sincere remarks. In Experiment 2, both the TS-alone and TS+ADHD groups performed below the level of the control participants on the comprehension of indirect sarcasm items but not on the comprehension of direct sarcasm items and sincere items. Those with TS+ADHD also performed below the level of the control participants on measures of interference control and fluency. The findings are discussed with reference to the possible contribution of executive functioning and mentalizing to the patterns of performance.

Electrophysiological correlates of reinforcement learning in young people with Tourette syndrome with and without co-occurring ADHD symptoms

Altered reinforcement learning is implicated in the causes of Tourette syndrome (TS) and attention-deficit/hyperactivity disorder (ADHD). TS and ADHD frequently co-occur but how this affects reinforcement learning has not been investigated. We examined the ability of young people with TS (n=18), TS+ADHD (N=17), ADHD (n=13) and typically developing controls (n=20) to learn and reverse stimulus-response (S-R) associations based on positive and negative reinforcement feedback. We used a 2 (TS-yes, TS-no)×2 (ADHD-yes, ADHD-no) factorial design to assess the effects of TS, ADHD, and their interaction on behavioural (accuracy, RT) and event-related potential (stimulus-locked P3, feedback-locked P2, feedback-related negativity, FRN) indices of learning and reversing the S-R associations. TS was associated with intact learning and reversal performance and largely typical ERP amplitudes. ADHD was associated with lower accuracy during S-R learning and impaired reversal learning (significantly reduced accuracy and a trend for smaller P3 amplitude). The results indicate that co-occurring ADHD symptoms impair reversal learning in TS+ADHD. The implications of these findings for behavioural tic therapies are discussed.

WITHDRAWN: Electrophysiological correlates of reinforcement learning in young people with Tourette syndrome with and without co-occurring ADHD symptoms

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.ijdevneu.2016.04.006. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Cognitive Flexibility and Social Responsiveness in Children and Adolescents with Tourette Syndrome

This study examined cognitive flexibility and social responsiveness in children and adolescents with Tourette Syndrome (TS). Thirty one subjects with TS were compared to 32 age-matched healthy controls. Assessments included semi-structured interviews to assess psychopathology, parent-rated Social Responsiveness Scale (SRS) and a brief neuropsychological battery selected as measures of cognitive flexibility. Completion time for both Trail Making Tests (TMT-A and TMT-B) were significantly longer for TS group than controls, however the difference in perseverative errors on Wisconsin Card Sorting Test (WCST) was not significant. SRS total score was significantly higher in the TS group compared to controls, indicating greater impairment in social responsiveness. Group difference for TMTs and SRS failed to reach significance after controlling for co-occurring conditions. Clinicians might consider social impairment in the evaluation plan of children and adolescents with Tourette syndrome.

Tourette and tic disorders in ICD-11: standing at the diagnostic crossroads

This article reflects discussion by the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders. After reviewing the historical classification of tic disorders, this article discusses their placement in ICD-11. Existing problems with diagnostic labels and criteria, appropriate placement of the tic disorders category within the ICD-11 system, and pragmatic factors affecting classification are reviewed. The article ends with recommendations to (a) maintain consistency with the DSM-5 diagnostic labels for tic disorders, (b) add a minimum duration guideline for a provisional tic disorder diagnosis, (c) remove the multiple motor tic guideline for the diagnosis of Tourette disorder, and (d) co-parent the tic disorder diagnoses in the disorders of the nervous system and the mental and behavioral disorders categories, with secondary co-parenting in the obsessive-compulsive and related disorders and neurodevelopmental disorders sections.

Neurofeedback and its possible relevance for the treatment of Tourette syndrome

Neurofeedback is an increasingly recognized therapeutic option in various neuropsychiatric disorders to treat dysfunctions in cognitive control as well as disorder-specific symptoms. In this review we propose that neurofeedback may also reflect a valuable therapeutic option to treat executive control functions in Gilles-de-la-Tourette syndrome (GTS). Deficits in executive control functions when ADHD symptoms appear in GTS likely reflect pathophysiological processes in cortico-thalamic-striatal circuits and may also underlie the motor symptoms in GTS. Such executive control deficits evident in comorbid GTS/ADHD depend on neurophysiological processes well-known to be modifiable by neurofeedback. However, so far efforts to use neurofeedback to treat cognitive dysfunctions are scarce. We outline why neurofeedback should be considered a promising treatment option, what forms of neurofeedback may prove to be most effective and how neurofeedback may be implemented in existing intervention strategies to treat comorbid GTS/ADHD and associated dysfunctions in cognitive control. As cognitive control deficits in GTS mostly appear in comorbid GTS/ADHD, neurofeedback may be most useful in this frequent combination of disorders.

Social reasoning in Tourette syndrome

INTRODUCTION

Tourette syndrome (TS) is thought to be associated with striatal dysfunction. Changes within frontostriatal pathways in TS could lead to changes in abilities reliant on the frontal cortex. Such abilities include executive functions and aspects of social reasoning.

METHODS

This study aimed to investigate executive functioning and Theory of Mind (ToM; the ability to reason about mental states, e.g., beliefs and emotions), in 18 patients with TS and 20 controls. A range of tasks involving ToM were used. These required participants to make judgements about mental states based on pictures of whole faces or the eyes alone, reason about humour in cartoons that featured sarcasm, irony or "slapstick" style humour, and make economic decisions. The executive measures assessed inhibition and verbal fluency.

RESULTS

Patients with TS exhibited significantly poorer performance than controls on all four tasks involving ToM, even when patients with comorbid obsessive-compulsive disorder were excluded. These difficulties were despite no inhibitory deficits. Patients with TS exhibited impairment on the verbal fluency task but their performance on executive and ToM tasks was not related.

CONCLUSIONS

We propose that TS is associated with changes in ToM. The observed deficits could reflect dysfunction in frontostriatal pathways involving ventromedial prefrontal cortex.

Judgements of social inappropriateness in adults with Tourette's syndrome

INTRODUCTION

Socially inappropriate behaviour has frequently been reported in Tourette's syndrome (TS), but has not been studied experimentally. The current study was designed to examine the appropriateness of self-disclosures in TS using an emotional self-disclosure task.

METHODS

Adult participants with TS-alone (20) and matched controls (20) were compared on two social judgement tasks, one examining the regulation of behaviour in an emotional self-disclosure task requiring participants to generate examples of autobiographical events, and the other examining mentalistic judgement of others' behaviour on a faux pas task.

RESULTS

Those with TS-alone and controls showed no group differences for judges' or participants' ratings of inappropriateness on the self-disclosure task, although only the self-ratings of the control group corresponded to the judges' ratings. On the faux pas task, those with TS-alone were impaired relative to controls in detecting socially inappropriate behaviour. There was also some evidence of executive dysfunction in the TS-alone group.

CONCLUSIONS

TS-alone is linked to a mixed pattern of preserved and impaired performance on social cognition measures, and further work is needed to determine the contributions of social and/or executive contributions to everyday functioning.

Impaired comprehension of nonliteral language in Tourette syndrome

OBJECTIVE

To investigate theory of mind and the understanding of nonliteral language in patients with Tourette syndrome (TS).

BACKGROUND

In TS, striatal dysfunction could affect the functioning of the frontal cortex. Changes in frontal functioning could lead to impairments in theory of mind: the understanding of mental states, such as beliefs, emotions, and intentions. Poor understanding of a speaker's mental state may also impair interpretation of their nonliteral remarks.

METHOD

In this study, patients with TS and healthy controls completed tasks to assess their understanding of sarcasm, metaphor, indirect requests, and theory of mind. These tasks were the Pragmatic Story Comprehension Task, the Hinting task, and a faux pas task. Inhibitory ability was also assessed through the use of the Hayling task and a black and white Stroop test.

RESULTS

Patients with TS exhibited significant impairment on the faux pas task and Pragmatic Story Comprehension Task despite limited evidence of inhibitory impairment.

CONCLUSION

TS may be associated with changes in theory of mind.

Behavioral interventions for tic disorders

A variety of treatment approaches have been used to manage tic symptoms in Tourette syndrome and other tic disorders. Pharmacological interventions remain the most common approach, but in the past 3 decades, various nonpharmacological treatment options have emerged including: (1) massed practice, (2) relaxation training, (3) self-monitoring, (4) function-based/contingency management procedures, (5) habit reversal training, (6) exposure and response prevention, and (7) cognitive behavior therapy. Each of these procedures is described along with the evidence reflecting its efficacy and usefulness. A synthesis of the findings and implications is provided, including directions and recommendations for future treatment and research.

Affective and cognitive Theory of Mind in patients with parkinson's disease

Theory of Mind (ToM), which is the ability to infer other people's mental states such as beliefs or desires, is an important prerequisite for social interaction. Affective and cognitive subcomponents of ToM can be impaired selectively in neurological and psychiatric disorders. This study examines ToM in 21 Parkinson's disease (PD) patients and 21 healthy control (HC) subjects, using the computerized "Yoni task" that assesses affective and cognitive ToM abilities and an extensive battery of neuropsychological tests. Furthermore, questionnaires to assess health-related quality of life and depressive symptoms were applied and correlations to ToM were investigated. Compared to the control subjects, PD patients scored lower on both the affective (PD: 76% versus HC: 89%; p = 0.006) and cognitive (PD: 80% versus HC: 92%; p = 0.002) ToM subscales but not on control items (PD: 90% versus HC: 95%; p = 0.077). The ToM abilities were not associated with other cognitive functions, depressive symptoms or clinical data. However, affective ToM was correlated with health-related quality of life (p = 0.01). Parkinson patients are impaired in affective as well as cognitive ToM. These deficits are largely independent from other cognitive impairments, depressive symptoms and motor impairment. The relationship of affective ToM to the health-related quality of life of PD patients points to a clinical relevance of this issue and suggests that ToM dysfunctions must be regarded as an important non-motor feature of Parkinson's disease.

Neuropsychological aspects of Tourette syndrome: a review

Tourette syndrome (TS) is assumed to result from frontostriatal dysfunction, which would be expected to result in impairments in neuropsychological functions. This possibility has been explored in a number of studies that have assessed the performance of patients with TS within major cognitive domains and on tests involving executive functioning. We aim to summarize the main findings of these studies while evaluating the influence of task limitations and potentially critical confounding factors such as the presence of comorbidity. Although there is clearly a need for improved study design, we tentatively suggest that there is considerable evidence for cognitive impairment in a subgroup of patients, and that some difficulties seem to be intrinsic to TS. These impairments may reflect dysfunction of the anterior cingulate network within the frontostriatal pathway.

Inhibitory deficits in Tourette's syndrome

A developmental approach to the study of psychopathology can broaden understanding of a wide variety of complex psychological disorders. This article reviews research on Tourette's syndrome (TS), a developmental disorder characterized by unwanted motor and vocal tics. Over the past decade, knowledge of the neurobiology and pathophysiology of TS has progressed rapidly. The application of brain imaging techniques, primarily magnetic resonance imaging, to the study of Tourette's has increased knowledge of structural and functional deficits in brain areas associated with behavioral and psychological disturbances in the disorder. By reviewing some of this work, we will describe one way in which knowledge of brain function in TS has both informed and been informed by a developmental science approach. In particular, we will consider the extent to which the cognitive and emotional development of persons with TS may be affected by specific neurobiological characteristics of the disorder.

Executive functions in children with chronic tic disorders with/without ADHD: new insights

OBJECTIVE

In Chronic Tic Disorders (CTD) associated Attention Deficit Hyperactivity Disorder (ADHD) is very common. Hence, it is important to clarify how both conditions are related to cognitive dysfunctions in patients with CTD+ADHD comorbidity. Recent studies on neuropsychology revealed equivocal results, mostly due to methodological shortcomings like problems in sample composition. Thus better and more detailed information on this topic is needed to improve diagnostic and treatment approaches.

METHOD

Three tasks related to different domains of executive functions (the Matching Familiar Figures Test, the Stroop color-word interference task, and a computerized version of the Wisconsin Card Sorting Test) have been performed in two independent samples (altogether n = 138 children) both including four groups of children (CTD-only, CTD+ADHD, ADHD-only, healthy controls) matched for age and IQ. To specify the influence of either tics or ADHD-symptoms on executive functions and to answer the question of their interactive or additive relationship two-way analyses of variance (MANOVA) for the factors CTD (yes,-no) x ADHD (yes,no) were conducted. Eta squared was calculated to reveal the effect sizes for each factor. For a deeper understanding of group differences and to better enable the comparison with data in literature, additional analyses of variance (ANOVA) with posthoc testing were applied.

RESULTS

In summary, there was a main effect only for the factor ADHD reflected by decreased performance, while no main effect of the factor CTD could be found. Admittedly, the effects were not uniform in both samples. However, in all three tasks and both samples, uniformly no interaction between the main factors has been observed.

CONCLUSIONS

In cases of coexisting CTD+ADHD the factor ADHD shows the main negative impact on neuropsychological performance and this impact seems to be independent of any feature of the coexisting tics (additive model). This supports the notion to primarily treat the ADHD-symptoms in order to increase cognitive self regulatory abilities of these children. Contrarily, tics seem to have little impact on cognitive performance in most cases.

Attention deficit hyperactivity disorder, tics and Tourette's syndrome: the relationship and treatment implications. A commentary

Tourette's Syndrome (TS) is now recognised to be a common childhood onset neurodevelopmental disorder. Attention deficit hyperactivity disorder (ADHD) is also a common childhood disorder. There are many cases in which the two disorders are comorbid. The reasons for this are unclear, but the comorbidity does not necessarily point to one genetic cause. Sleep is also often disturbed in individuals with TS and ADHD. The treatment implications of ADHD in the setting of tics or TS are important. Clonidine is suggested as a first line treatment. It was once thought that stimulants were contraindicated in the treatment of ADHD in the setting of TS, whereas it is suggested that they may be safe, but should be used judiciously. In addition, it was once thought that the combination of stimulants and clonidine was contraindicated, but from a large study the combination does appear to be safe. A relatively new medication for ADHD is atomoxetine, and although not documented widely in the setting of tics and TS, it may prove useful in this setting; further research is required. This commentary briefly discusses the comorbidity between TS and ADHD and offers treatment suggestions.

Investigation of response inhibition in obsessive-compulsive disorder using the Hayling task

This study investigates response inhibition deficits in obsessive-compulsive disorder (OCD) by using the Hayling task. Sixteen OCD washers, 16 OCD checkers, 16 social phobic patients and 16 nonanxious controls were asked to complete sentences with either the expected word (section A: "initiation") or an unrelated word (section B: "inhibition"). The groups did not differ in terms of section B minus section A latencies. However, OCD washers and checkers made significantly more errors (sentence-related responses) in section B than social phobic patients and controls. In the OCD patients, the frequency of these errors correlates with the total OCD severity score and the compulsion subscore, but not with the depression and anxiety scores. These findings suggest that OCD patients might present a specific deficit affecting the inhibition of a prepotent response.