The prevalence and epidemiology of Gilles de la Tourette syndrome. Part 2: tentative explanations for differing prevalence figures in GTS, including the possible effects of psychopathology, aetiology, cultural differences, and differing phenotypes

Diffusion indices alteration in major white matter tracts of children with tic disorder using TRACULA

BACKGROUND

Tic disorder is a neuropsychiatric disorder characterized by involuntary movements or vocalizations. Previous studies utilizing diffusion-weighted imaging to explore white-matter alterations in tic disorders have reported inconsistent results regarding the affected tracts. We aimed to address this gap by employing a novel tractography technique for more detailed analysis.

METHODS

We analyzed MRI data from 23 children with tic disorders and 23 healthy controls using TRActs Constrained by UnderLying Anatomy (TRACULA), an advanced automated probabilistic tractography method. We examined fractional anisotropy (FA), radial diffusivity (RD), axial diffusivity, and mean diffusivity in 42 specific significant white matter tracts.

RESULTS

Our findings revealed notable differences in the children with tic disorders compared to the control group. Specifically, there was a significant reduction in FA in the parietal part and splenium of the corpus callosum and the left corticospinal tract. Increased RD was observed in the temporal and splenium areas of the corpus callosum, the left corticospinal tract, and the left acoustic radiation. A higher mean diffusivity was also noted in the left middle longitudinal fasciculus. A significant correlation emerged between the severity of motor symptoms, measured by the Yale Global Tic Severity Scale, and FA in the parietal part of the corpus callosum, as well as RD in the left acoustic radiation.

CONCLUSION

These results indicate a pattern of reduced interhemispheric connectivity in the corpus callosum, aligning with previous studies and novel findings in the diffusion indices changes in the left corticospinal tract, left acoustic radiation, and left middle longitudinal fasciculus. Tic disorders might involve structural abnormalities in key white matter tracts, offering new insights into their pathogenesis.

The Challenge of Examining Social Determinants of Health in People Living With Tourette Syndrome

BACKGROUND

To examine the association between race, ethnicity, and parental educational attainment on tic-related outcomes among Tourette Syndrome (TS) participants in the Tourette Association of America International Consortium for Genetics (TAAICG) database.

METHODS

723 participants in the TAAICG dataset aged ≤21 years were included. The relationships between tic-related outcomes and race and ethnicity were examined using linear and logistic regressions. Parametric and nonparametric tests were performed to examine the association between parental educational attainment and tic-related outcomes.

RESULTS

Race and ethnicity were collapsed as non-Hispanic white (N=566, 88.0%) versus Other (N=77, 12.0%). Tic symptom onset was earlier by 1.1 years (P < 0.0001) and TS diagnosis age was earlier by 0.9 years (P = 0.0045) in the Other group (versus non-Hispanic white). Sex and parental education as covariates did not contribute to the differences observed in TS diagnosis age. There were no significant group differences observed across the tic-related outcomes in parental education variable.

CONCLUSIONS

Our study was limited by the low number of nonwhite or Hispanic individuals in the cohort. Racial and ethnic minoritized groups experienced an earlier age of TS diagnosis than non-Hispanic white individuals. Tic severity did not differ between the two groups, and parental educational attainment did not affect tic-related outcomes. There remain significant disparities and gaps in knowledge regarding TS and associated comorbid conditions. Our study suggests the need for more proactive steps to engage individuals with tic disorders from all racial and ethnic minoritized groups to participate in research studies.

Caregiver Perspectives on the Health Care System for Tic Disorders: Utilization and Barriers

OBJECTIVE

This study aimed to understand health care experiences among a sample of caregivers of children with TDs to inform future directions for improving the health care system.

METHODS

We conducted a survey of caregivers of youth with TDs and used descriptive statistics and quantitative analyses to characterize the health care utilization practices of the sample.

RESULTS

The majority (70%) of families first consulted their pediatrician/primary care provider, and caregivers reported receiving care in line with current best practice guidelines. However, caregivers in the current sample perceived a lack of knowledgeability on the part of their first providers, which significantly predicted more providers seen and also reported difficulty finding specialty providers (63% of the sample reported difficulty finding a treatment provider who understood tics).

CONCLUSION

Results suggest that improving caregiver satisfaction with early health care experiences for their child's TD may help to relieve the burden on families and the health care system more broadly, along with continued efforts to increase the number of specialty providers available.

The Role of the Left Inferior Parietal Cortex in Gilles de la Tourette Syndrome—An rTMS Study

Increased activity in the left inferior parietal cortex (BA40) plays a role in the generation of tics in the Gilles de la Tourette syndrome (GTS). Thus, inhibitory repetitive transcranial magnetic stimulation (rTMS) applied to BA40 was hypothesized to alleviate symptoms in GTS. We investigated the immediate effects of single-session 1 Hz rTMS and sham stimulation delivered to the left BA40 on tics assessed with the Rush video protocol in 29 adults with GTS. There were no significant effects on tic symptoms following rTMS or sham stimulation. Moreover, there was no difference when comparing the effects of both stimulation conditions. Bayesian statistics indicated substantial evidence against an intervention effect. The left BA40 appears not to be a useful target for 1 Hz rTMS to modulate tic symptoms in GTS patients.

Evaluation of new instruments for screening and diagnosis of tics and tic disorders in a well-characterized sample of youth with tics and recruited controls

Tics and tic disorders can significantly impact children, but limited screening tools and diagnostic challenges may delay access to care. The current study attempted to address these gaps by evaluating sensitivity and specificity of the Motor or Vocal Inventory of Tics (MOVeIT), a tic symptom screener, and the Description of Tic Symptoms (DoTS), a brief diagnostic assessment for tic disorders. Children (n=100, age 6-17 years old) with tic disorders attending a Tourette specialty clinic and a community-recruited sample without tics completed a gold-standard assessment by a tic expert; these evaluations were compared to child self-report and parent and teacher report versions of the MOVeIT, and child and parent versions of the DoTS. The parent and child MOVeIT met or exceeded pre-specified 85% sensitivity and specificity criteria for detecting the presence of tics when compared to a gold-standard tic expert diagnosis. The Teacher MOVeIT had lower sensitivity (71.4%) but good specificity (95.7%) for identifying any tic symptoms compared to gold standard. For determination of the presence or absence of any tic disorder, sensitivity of both parent and child DoTS was 100%; specificity of the parent DoTS was 92.7% and child DoTS specificity was 75.9%. More work may be needed to refine the teacher MOVeIT, but it is also recognized that tic expression may vary by setting. While the MOVeIT and DoTS parent and child questionnaires demonstrated adequate sensitivity and specificity for determining the presence of tics and tic disorders in this well-defined sample, additional testing in a general population is warranted.

Maternal Copy Number Imbalances in Non-Invasive Prenatal Testing: Do They Matter?

Non-invasive prenatal testing (NIPT) has become a routine practice in screening for common aneuploidies of chromosomes 21, 18, and 13 and gonosomes X and Y in fetuses worldwide since 2015 and has even expanded to include smaller subchromosomal events. In fact, the fetal fraction represents only a small proportion of cell-free DNA on a predominant background of maternal DNA. Unlike fetal findings that have to be confirmed using invasive testing, it has been well documented that NIPT provides information on maternal mosaicism, occult malignancies, and hidden health conditions due to copy number variations (CNVs) with diagnostic resolution. Although large duplications or deletions associated with certain medical conditions or syndromes are usually well recognized and easy to interpret, very little is known about small, relatively common copy number variations on the order of a few hundred kilobases and their potential impact on human health. We analyzed data from 6422 NIPT patient samples with a CNV detection resolution of 200 kb for the maternal genome and identified 942 distinct CNVs; 328 occurred repeatedly. We defined them as multiple occurring variants (MOVs). We scrutinized the most common ones, compared them with frequencies in the gnomAD SVs v2.1, dbVar, and DGV population databases, and analyzed them with an emphasis on genomic content and potential association with specific phenotypes.

Jing-an oral liquid alleviates Tourette syndrome via the NMDAR/MAPK/CREB pathway in vivo and in vitro

CONTEXT

Jing-an oral liquid (JA) is a Chinese herbal formula used in the treatment of Tourette syndrome (TS); however, its mechanism is unclear.

OBJECTIVE

To investigate the effects of JA on amino acid neurotransmitters and microglia activation in vivo and in vitro.

MATERIALS AND METHODS

Sixty male Sprague-Dawley rats were divided into a control group and 5 TS groups. TS was induced in rats with intraperitoneal injection of 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (1 mg/kg) and in BV2 cells with lipopolysaccharide. Control and model rats were administered saline, whereas treatment groups were administered JA (5.18, 10.36, or 20.72 g/kg) or tiapride (a benzamide, 23.5 mg/kg) by gavage once daily for 21 days. Stereotypic behaviour was tested. The levels of N-methyl-d-aspartate receptor (NMDAR)/mitogen-activated protein kinase/cAMP response element-binding protein (CREB)-related proteins in striatum and BV2 cells were measured via western blots. CD11b and IBa1 levels were also measured. Ultra-high-performance liquid-chromatography was used to determine γ-aminobutyric acid (GABA), glutamic acid (Glu), and aspartic acid (ASP) levels.

RESULTS

JA markedly alleviated the stereotype behaviour (25.92 ± 0.35 to 13.78 ± 0.47) in rats. It also increased NMDAR1 (0.48 ± 0.09 to 0.67 ± 0.08; 0.54 ± 0.07 to 1.19 ± 0.18) expression and down-regulated the expression of p-ERK, p-JNK, p-P38, and p-CREB in BV2 cells and rat striatum. Additionally, Glu, ASP, GABA, CD11b, and IBa1 levels were significantly decreased by JA.

DISCUSSION AND CONCLUSIONS

JA suppressed microglia activation and regulated the levels of amino acid neurotransmitters, indicating that it could be a promising therapeutic agent for TS.

Potential Plasma Metabolic Biomarkers of Tourette Syndrome Discovery Based on Integrated Nontargeted and Targeted Metabolomics Screening Plasma Metabolic Biomarkers of TS

Objective

Tourette syndrome (TS) is a chronic neuropsychiatric disorder characterized by abnormal movements, phonations, and tics, but an accurate TS diagnosis remains challenging and indeed depends on its description of clinical symptoms. Our study was conducted to discover and verify some metabolite biomarkers based on nontargeted and targeted metabolomics.

Methods

We conducted untargeted ultrahigh-performance liquid chromatography-quadrupole time-of-flight mass spectrometry (UHPLC-Q-TOF/MS) for preliminary screening of potential biomarkers on 30 TS patients and 10 healthy controls and then performed validation experiments based on targeted ultrahigh-performance liquid chromatography triple quadrupole-MS (UHPLC/MS/MS) on 35 TS patients and 14 healthy controls.

Results

1775 differentially expressed metabolites were identified by partial least squares discriminant analysis (PLS-DA), fold-change analysis, T-test, and hierarchical clustering analysis (adjusted p value <0.05 and |logFC| > 1). TS plasma samples were found to be differentiated from healthy samples in our approach. Furthermore, aspartate and asparagine metabolism pathways were considered to be a significant enrichment pathway in TS progression based on metabolite pathway enrichment analysis. For the 8 metabolites involved in this pathway that we detected, we then performed validation experiments based on targeted UHPLC/MS/MS. The t-test, Mann-Whitney U test, and receiver operating characteristic (ROC) curve analysis were used to determine potential biomarkers. Ultimately, L-arginine and L-pipecolic acid were validated as significantly differentiated metabolites (p < 0.05), with an AUC of 70.0% and 80.3%, respectively.

Conclusion

L-pipecolic acid was defined as a potential biomarker for TS diagnosis by the combined application of nontargeted and targeted metabolomic analysis.

Overcoming the phenomenological Perpetuum mobile in clinical cognitive neuroscience for the benefit of replicability in research and the societal view on mental disorders

Cognitive neuroscience comes in many facets, and a particularly large branch of research is conducted in individuals with mental health problems. This article outlines why it is important that cognitive neuroscientists re-shape their role in mental health research and re-define directions of research for the next decades. At present, cognitive neuroscience research in mental health is too firmly rooted in categorial diagnostic definitions of mental health conditions. It is discussed why this hampers a mechanistic understanding of brain functions underlying mental health problems and why this is a problem for replicability in research. A possible solution to these problems is presented. This solution affects the strategy of research questions to be asked, how current trends to increase replicability in research can or cannot be applied in the mental health field and how data are analyzed. Of note, these aspects are not only relevant for the scientific process, but affect the societal view on mental disorders and the position of affected individuals as members of society, as well as the debate on the inclusion of so-called WEIRD and non-WEIRD people in studies. Accordingly, societal and science political aspects of re-defining the role of cognitive neuroscientists in mental health research are elaborated that will be important to shape cognitive neuroscience in mental health for the next decades.

Incidence and prevalence of Tourette syndrome and chronic tic disorders in Taiwan: a nationwide population-based study

PURPOSE

The incidence of Tourette syndrome and chronic tic disorders has seldom been evaluated in Asia.

METHODS

Using the National Taiwan Insurance Research Database, the annual standardized incidence and prevalence of Tourette syndrome (TS) and chronic tic disorders were estimated from 2007 to 2015. The pre-existing comorbidity at disease diagnosis was also evaluated.

RESULTS

From 2007 to 2015, the age- and sex-standardized incidence increased from 5.34 (95% confidence interval [CI] 5.06-5.62) per 100,000 person-years to 6.87 (95% CI 6.53-7.21) per 100,000 person-years. In children and adolescents, the age- and sex-standardized incidence increased from 19.58 (95% CI 18.42-20.75) per 100,000 person-years to 31.79 (95% CI 30.09-33.49) per 100,000 person-years. In adults, the age- and sex-standardized incidence decreased from 2.01 (95% CI 1.79-2.23) per 100,000 person-years to 1.24 (95% CI 1.07-1.42) per 100,000 person-years. The incidence rate ratio (IRR) between males and females was 3.74 (95% CI 3.32-4.22). The age- and sex-standardized prevalence increased from 37.51 (95% CI 36.75-38.27) per 100,000 people in 2007 to 84.18 (95% CI 83.02-85.35) per 100,000 people in 2015. The rate risk (RR) between males and females was 3.65 (95% CI 3.53-3.78).

CONCLUSION

The annual incidence rates of TS and chronic tic disorders increased in childhood and adolescence but decreased in adulthood from 2007 to 2015. The prevalence rates increased over the same period.

Academic, Interpersonal, Recreational, and Family Impairment in Children with Tourette Syndrome and Attention-Deficit/Hyperactivity Disorder

This study describes impairment in academic, interpersonal, recreational, and family financial or occupational domains across children in three mutually exclusive diagnostic groups: ever diagnosed with Tourette syndrome (TS), attention-deficit/hyperactivity disorder (ADHD), and both disorders. In 2014, parents reported on impairment and diagnostic status of children aged 4-17 years (n = 3014). Weighted analysis and pairwise t-tests showed more children with ADHD (with or without TS) experienced impairment in overall school performance, writing, and mathematics, relative to children with TS but not ADHD. More children with TS and ADHD had problematic handwriting relative to children with ADHD but not TS. More children with TS and ADHD had problematic interpersonal relationships relative to those with ADHD but not TS. Children with TS and ADHD had higher mean impairment across domains than children with either TS or ADHD. Findings suggest assessing disorder-specific contributions to impairment could inform targeted interventions for TS and ADHD.

Hair cortisol-a stress marker in children and adolescents with chronic tic disorders? A large European cross-sectional study

BACKGROUND

There is clear evidence that tic disorders (TDs) are associated with psychosocial stress as well as emotional and behavioral problems. Studies have shown that individuals with TDs have higher acute physiological stress responses to external, single stressors (as reflected by saliva cortisol). The aim of the present study was to examine a physiological marker of longer-term stress (as reflected by hair cortisol concentration) in children and adolescents with TDs and unaffected siblings of individuals with TDs.

METHODS

Two samples of a European cohort were included in this study. In the COURSE sample, 412 children and adolescents aged 3-16 years with a chronic TD including Tourette syndrome according to DSM IV-TR criteria were included. The ONSET sample included 131 3-10 years old siblings of individuals with TDs, who themselves had no tics. Differences in hair cortisol concentration (HCC) between the two samples were examined. Within the COURSE sample, relations of HCC with tic severity and perceived psychosocial stress as well as potential effects and interaction effects of comorbid emotional and behavioral problems and psychotropic medication on HCC were investigated.

RESULTS

There were no differences in HCC between the two samples. In participants with TDs, there were no associations between HCC and tic severity or perceived psychosocial stress. No main effects of sex, psychotropic medication status and comorbid emotional and behavioral problems on HCC were found in participants with TDs.

CONCLUSION

A link between HCC and TDs is not supported by the present results.

Distinct Brain-Oscillatory Neuroanatomical Architecture of Perception-Action Integration in Adolescents With Tourette Syndrome

Background

Gilles de la Tourette Syndrome (GTS) is a neurodevelopmental disorder with a peak of symptom severity around late childhood and early adolescence. Previous findings in adult GTS suggest that changes in perception-action integration, as conceptualized in the theory of event coding framework, are central for the understanding of GTS. However, the neural mechanisms underlying these processes in adolescence are elusive.

Methods

A total of 59 children/adolescents aged 9 to 18 years (n = 32 with GTS, n = 27 typically developing youths) were examined using a perception-action integration task (event file task) derived from the theory of event coding. Event-related electroencephalogram recordings (theta and beta band activity) were analyzed using electroencephalogram–beamforming methods.

Results

Behavioral data showed robust event file binding effects in both groups without group differences. Neurophysiological data showed that theta and beta band activity were involved in event file integration in both groups. However, the functional neuroanatomical organization was markedly different for theta band activity between the groups. The typically developing group mainly relied on superior frontal regions, whereas the GTS group engaged parietal and inferior frontal regions. A more consistent functional neuroanatomical activation pattern was observed for the beta band, engaging inferior parietal and temporal regions in both groups.

Conclusions

Perception-action integration processes lag behind in persisting GTS but not in the GTS population as a whole, underscoring differences in developmental trajectories and the importance of longitudinal investigations for the understanding of GTS. The findings corroborate known differences in the functional/structural brain organization in GTS and suggest an important role of theta band activity in these patients.

A Comprehensive Review of Tic Disorders in Children

Tics are characterized by sudden, rapid, recurrent, nonrhythmic movement or vocalization, and are the most common movement disorders in children. Their onset is usually in childhood and tics often will diminish within one year. However, some of the tics can persist and cause various problems such as social embarrassment, physical discomfort, or emotional impairments, which could interfere with daily activities and school performance. Furthermore, tic disorders are frequently associated with comorbid neuropsychiatric symptoms, which can become more problematic than tic symptoms. Unfortunately, misunderstanding and misconceptions of tic disorders still exist among the general population. Understanding tic disorders and their comorbidities is important to deliver appropriate care to patients with tics. Several studies have been conducted to elucidate the clinical course, epidemiology, and pathophysiology of tics, but they are still not well understood. This article aims to provide an overview about tics and tic disorders, and recent findings on tic disorders including history, definition, diagnosis, epidemiology, etiology, diagnostic approach, comorbidities, treatment and management, and differential diagnosis.

Commentary: What is unsought will go undetected - a commentary on Rodin et al. (2020)

Rodin et al.'s study (2020) on the belief, knowledge and attitudes about tics amongst health professionals in Uganda is a preliminary yet an important step towards challenging the current thinking amongst clinicians and academics working with tics, which is that tics are hardly seen in or are absent in the sub-Saharan African population and it has been psotulated that this phenomenon is considered to be explained by genetics.

Why don't children in Uganda have tics? A mixed-methods study of beliefs, knowledge, and attitudes of health professionals

BACKGROUND

Tourette syndrome (TS) is reported in all cultures, although is speculated to be rare among those of Sub-Saharan African descent. A lack of research exploring TS in the context of Sub-Saharan Africa has meant that it is not yet established whether this apparent rarity is due to a true low prevalence or if identification of the condition merely is unrecognized. The present study aimed to explore health professionals' knowledge and attitudes of the identification, diagnosis and management of TS in Uganda.

METHOD

A mixed-methods design was used to collect data from 152 Ugandan healthcare professionals by survey. Of these, 6 professionals took part in semi-structured interviews. Data gathered were analyzed with descriptive statistics and qualitatively using thematic analysis.

RESULTS

Professionals' views and experiences led to conclusions addressing (a) perceived challenges in diagnosing and treating TS in a Ugandan healthcare setting, (b) the role of cultural factors in help-seeking behaviors, and (c) ways by which efforts can be made to build capacity in awareness and clinical care.

CONCLUSIONS

The findings suggest that TS is present in Uganda, but a number of factors hinder detection rates causing it to be under-reported in the population. This study highlights the need for more focused and adequate training for all healthcare professionals in Uganda and education campaigns to increase awareness among the general public.

KEY PRACTITIONER MESSAGE

Little is currently known about the presentation of or understanding by professionals around Tourette syndrome in Sub-Saharan Africa. This study found health professionals in Uganda indicated a number of factors which interact and negatively impact recognition rates of tic disorders. This included limited training, exposure, and misconceptions, contributing to a lack of clinical awareness and attention. They also reported a lack of help-seeking behaviors due to parental perceptions and Ugandan traditional, cultural and religious beliefs. Professionals perceive that there are likely large numbers of undiagnosed and untreated children with Tourette syndrome in Uganda. This supports existing literature regarding the diagnostic challenges of neurodevelopmental disorders in Africa and provides an alternative explanation for the assumption that tic disorders may be rare and possible absent in Sub-Saharan Africa. There is a need to develop adequate training regarding tic disorders for all healthcare professionals working in Uganda as well as education campaigns for the general public to increase awareness.

Impaired Motor Timing in Tourette Syndrome: Results From a Case-Control Study in Children

Tourette syndrome (TS) is a neurodevelopmental disorder characterized by motor and vocal tics. Co-occurrence of attention-deficit/hyperactivity disorder (ADHD) or obsessive–compulsive disorder (OCD) is very frequent in the pediatric population as well as the presence of an impairment of the executive functions. The aim of our study was to investigate motor timing, that is, the temporal organization of motor behavior, in a pediatric population of Tourette patients. Thirty-seven Tourette patients (divided in 22 “pure” Tourette patients and 15 with ADHD) were compared with 22 healthy age- and gender-matched subjects. All subjects underwent a neuropsychiatric screening and were tested for their planning and decision-making abilities by using a standardized test, such as Tower of London (ToL). Two experimental paradigms were adopted: finger-tapping test (FTT), a free motor tapping task, and synchronization–continuation task. An accuracy index was calculated as measure of ability of synchronization. We found that “pure” TS as well as TS+ADHD showed lower scores in the FTT for the dominant and non-dominant hands than controls. Moreover, in the synchronization and continuation test, we observed an overall lack of accuracy in both TS groups in the continuation phase for 2,000 ms (supra-second interval), interestingly, with opposite direction of accuracy index. Thus, “pure” TS patients were classified as “behind the beat,” whereas, TS+ADHD as “ahead of the beat.” The performance in the finger tapping was inversely correlated to ToL total scores and execution time, whereas we did not find any correlation with the accuracy index of the synchronization and continuation test. In conclusion, here, we explored motor timing ability in a childhood cohort of Tourette patients, confirming that patients exhibit an impaired temporal control of motor behavior and these findings may be explained by the common underlying neurobiology of TS and motor timing.

Tics and Tourette Syndrome

PURPOSE OF REVIEW

The purpose of this article is to present current information on the phenomenology, epidemiology, comorbidities, and pathophysiology of tic disorders and discuss therapy options. It is hoped that a greater understanding of each of these components will provide clinicians with the necessary information to deliver thoughtful and optimal care to affected individuals.

RECENT FINDINGS

Recent advances include the finding that Tourette syndrome is likely due to a combination of several different genes, both low-effect and larger-effect variants, plus environmental factors. Pathophysiologically, increasing evidence supports involvement of the cortical-basal ganglia-thalamocortical circuit; however, the primary location and neurotransmitter remain controversial. Behavioral therapy is first-line treatment, and pharmacotherapy is based on tic severity. Several newer therapeutic agents are under investigation (eg, valbenazine, deutetrabenazine, cannabinoids), and deep brain stimulation is a promising therapy.

SUMMARY

Tics, defined as sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations, are essential components of Tourette syndrome. Although some tics may be mild, others can cause significant psychosocial, physical, and functional difficulties that affect daily activities. In addition to tics, most affected individuals have coexisting neuropsychological difficulties (attention deficit hyperactivity disorder, obsessive-compulsive disorder, anxiety, mood disorder, disruptive behaviors, schizotypal traits, suicidal behavior, personality disorder, antisocial activities, and sleep disorders) that can further impact social and academic activities or employment.

Effectiveness of a modified comprehensive behavioral intervention for tics for children and adolescents with tourette's syndrome: A randomized controlled trial

AIM

To evaluate the effectiveness of a modified four-session Comprehensive Behavioral Intervention for Tics programme for decreasing tics in children and adolescents with Tourette's syndrome.

BACKGROUND

Comprehensive Behavioral Intervention for Tics programme has been shown to decrease tic severity. However, the lack of behaviour therapists in countries, such as in Taiwan, may preclude application of the standard eight-session, 10-week programme.

DESIGN

Randomized controlled study.

METHODS

Participants aged 6-18 years diagnosed with Tourette's syndrome or chronic tic disorder were recruited from February 2015 through September 2016. Participants in the control and intervention groups (N = 23 each) received the routine care (daily pyridoxine [50 mg] and psychoeducation). The intervention group received additional four behavioural intervention sessions over a 3-month period that included psychoeducation, habit reversal training, relaxation training, and education on tic relapse prevention. The outcome measures, Yale Global Tic Severity Scale scores, were assessed at before and after the completion of programme for both groups and again at 3 months follow-up for the intervention group. The effect of the intervention on severity scores was assessed using a generalized estimated equation.

RESULTS

Comparison of scores before and after intervention showed that the intervention significantly decreased the severity of total motor tics (B = -3.28, p < .01) and total tics (B = -5.86, p < .01) as compared with control treatment. YGTSS scores for the intervention group were lower at 3-month follow-up as compared with before treatment or immediately after treatment completion (total tics, p < .001).

CONCLUSION

The modified four-session Comprehensive Behavioral Intervention for Tics programme was more effective than routine care for decreasing tic severity in our cohort of 6- to 18-year olds. This improvement was maintained 3 months after intervention.

IMPACT

Healthcare providers, including nurses, in countries currently not adopting Comprehensive Behavioral Intervention for Tics programme should be made aware of the positive effects of this modified intervention for Tourette's syndrome.

Meta-analysis: Adulthood prevalence of Tourette syndrome

BACKGROUND

Tourette syndrome (TS) is estimated to have a prevalence of 0.30-0.77% in school aged children. Longitudinal studies suggest that roughly half-to-two-thirds of children with TS experience a substantial improvement in tic symptoms during adolescence. By contrast, few studies have examined adulthood prevalence of TS. Accurate prevalence estimates across the lifespan are needed to support regulatory and public health decisions.

METHODS

We searched PubMED and EMBASE for studies that examined the prevalence of TS in adults. We conducted a random-effects meta-analysis of logit event rates to estimate prevalence of TS across studies. Too few studies are available to conduct moderator analysis or examine publication bias. We also examined the risk ratio of TS prevalence in adults for males compared to females.

RESULTS

Three studies involving 2,356,485 participants were included. There were significant differences in TS adulthood prevalence estimates between studies ranging from 49 to 657 cases of TS per million adults. Overall prevalence of TS in adulthood was estimated to be 118 cases of TS per million adults (95%CI: 19-751 cases per million adults). There was a large amount of heterogeneity between studies (I² = 99%) that was likely related to differences in their methods of identification of TS cases. By contrast, the male:female ratio of risk of adulthood TS was similar between studies with a Risk Ratio = 2.33 (95% CI: 1.72-3.16).

CONCLUSION

Estimates of adulthood prevalence of TS are sparse and likely highly affected by differences in method of case identification. Diagnosis and diagnostic estimates of TS could be aided by including a requirement for impairment as well as potential remission criteria similar to other psychiatric conditions.

[Cognitive disturbances in children with chronic tics and their treatment]

AIM

To clarify the severity of cognitive disturbances in children with chronic tics and to evaluate the efficacy of cortexin as part of complex therapy in the treatment of this pathology.

MATERIAL AND METHODS

The main study group included 50 children, aged 6-8 years, with chronic motor tics. Twenty patients of these group received phenibut and 30 patients received cortexin in addition to phenibut. The comparison group consisted of 30 children with transient tics, aged 6-8 years, the control group consisted of 40 children of the same age without tics and other neuropsychiatric disorders. Clinical assessment of tick manifestations and their frequency was performed using the Tourette Syndrome Global Scale (TSGS), neurological examination, electroencephalography. Severity of asthenic and cognitive disorders was evaluated using the Subjective Asthenia Scale (MFI-20), the memorization technique by A.R. Luria and the TOVA test.

RESULTS AND CONCLUSION

Children with chronic tics show signs of asthenia, they are characterized by a higher level of inattention and significantly lower levels of long-term memory compared to children from the comparison group and the control group. The level of impulsivity in children with chronic tics is significantly higher than in the control group but significantly lower than in children in the comparison group. A comparative analysis of EEG data in children with chronic tics reveals the following significant differences from the control and comparison groups: a higher amplitude and higher values of the peak frequency of the alpha-rhythm in the posterior regions of both hemispheres, a significant increase in the alpha-range of the frontal temporal leads of both hemispheres. Complex therapy with the addition of cortexin significantly improves treatment efficacy: improvement is noted in 60,0% of patients in monotherapy and in 83.3% of patients in complex therapy.

European Multicentre Tics in Children Studies (EMTICS): protocol for two cohort studies to assess risk factors for tic onset and exacerbation in children and adolescents

Genetic predisposition, autoimmunity and environmental factors [e.g. pre- and perinatal difficulties, Group A Streptococcal (GAS) and other infections, stress-inducing events] might interact to create a neurobiological vulnerability to the development of tics and associated behaviours. However, the existing evidence for this relies primarily on small prospective or larger retrospective population-based studies, and is therefore still inconclusive. This article describes the design and methodology of the EMTICS study, a longitudinal observational European multicentre study involving 16 clinical centres, with the following objectives: (1) to investigate the association of environmental factors (GAS exposure and psychosocial stress, primarily) with the onset and course of tics and/or obsessive-compulsive symptoms through the prospective observation of at-risk individuals (ONSET cohort: 260 children aged 3-10 years who are tic-free at study entry and have a first-degree relative with a chronic tic disorder) and affected individuals (COURSE cohort: 715 youth aged 3-16 years with a tic disorder); (2) to characterise the immune response to microbial antigens and the host's immune response regulation in association with onset and exacerbations of tics; (3) to increase knowledge of the human gene pathways influencing the pathogenesis of tic disorders; and (4) to develop prediction models for the risk of onset and exacerbations of tic disorders. The EMTICS study is, to our knowledge, the largest prospective cohort assessment of the contribution of different genetic and environmental factors to the risk of developing tics in putatively predisposed individuals and to the risk of exacerbating tics in young individuals with chronic tic disorders.

Heroin Addiction in Serbian Patients With Tourette Syndrome

INTRODUCTION

Tourette syndrome (TS) is a neurodevelopmental disorder with a high prevalence of psychiatric comorbidity. The most common comorbid disorder in patients with TS is attention-deficit/hyperactivity disorder (ADHD). To date, there have been few reports concerning the association of TS with addiction.

METHODS

We report on 4 patients with TS, ADHD, and heroin addiction.

RESULTS

All 4 patients were male and initially presented with TS when they were between 5 and 12 years of age, although 2 of the patients were not diagnosed with TS until they were adults. The patients currently range in age from 21 to 52 years, all having experienced the onset of heroin addiction in adolescence. A reduction in tics during periods of heroin abuse was noted in all patients.

DISCUSSION

The lifetime prevalence of psychiatric comorbidity in patients with TS is 85.7%, with 57.7% of patients having ≥2 psychiatric conditions in addition to TS. All of the 4 patients in our case series demonstrated a pattern of severe tics, ADHD, impulsive behavior, and heroin addiction. Our observation that these 4 patients with TS showed reduced tics during periods of heroin dependence could be related to the previously described effects of opiates on dopaminergic transmission.

CONCLUSIONS

The observed reduction of tics during heroin dependence warrants further clinical research.

Electrophysiological predictors of cognitive-behavioral therapy outcome in tic disorders

Cognitive-behavioral therapy (CBT) constitutes an empirically based treatment for tic disorders (TD), but much remains to be learned about its impact at the neural level. Therefore, we examined the electrophysiological correlates of CBT in TD patients, and we evaluated the utility of event-related potentials (ERP) as predictors of CBT outcome. ERPs were recorded during a stimulus-response compatibility (SRC) task in 26 TD patients and 26 healthy controls. Recordings were performed twice, before and after CBT in TD patients, and with a similar time interval in healthy controls. The stimulus- and response-locked lateralized readiness potentials (sLRP & rLRP) were assessed, as well as the N200 and the P300. The results revealed that before CBT, TD patients showed a delayed sLRP onset and larger amplitude of both the sLRP and rLRP peaks, in comparison with healthy controls. The CBT induced an acceleration of the sLRP onset and a reduction of the rLRP peak amplitude. Compared to healthy controls, TD patients showed a more frontal distribution of the No-Go P300, which was however not affected by CBT. Finally, a multiple linear regression analysis including the N200 and the incompatible sLRP onset corroborated a predictive model of therapeutic outcome, which explained 43% of the variance in tic reduction following CBT. The current study provided evidence that CBT can selectively normalize motor processes relative to stimulus-response compatibility in TD patients. Also, ERPs can predict the amount of tic symptoms improvement induced by the CBT and might therefore improve treatment modality allocation among TD patients.

Systematic review of co-occurring OCD and TD: Evidence for a tic-related OCD subtype?

OBJECTIVE

The aim of this review is to summarize the current knowledge of associated features of co-occurring obsessive-compulsive disorder (OCD) and tic disorders (TD) and to critically evaluate hypotheses regarding the nature of their comorbidity.

METHOD

We conducted a systematic review following PRISMA guidelines. To this aim, the PubMed, PsychInfo and ISI Web of Knowledge databases were searched up to August 30, 2018. For gender and age-of-onset we additionally conducted meta-analyses.

RESULTS

One hundred eighty-nine studies met inclusion criteria. We substantiate some acknowledged features and report evidence for differential biological mechanisms and treatment response. In general, studies were of limited methodological quality.

CONCLUSIONS

Several specific features are reliable associated with co-occurring OCD + TD. The field lacks methodological sound studies. The review found evidence against and in favor for different hypotheses regarding the nature of comorbidity of OCD and TD. This could indicate the existence of a stepwise model of co-morbidity, or could be an artefact of the low methodological quality of studies.

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 Association of Poor Academic Performance with Tic Disorders: A Longitudinal, Mainstream School-Based Population Study

BACKGROUND

Little is known about the academic performance of students with tic disorders (TD). Our aim was to investigate the association of TD and poor academic performance over time.

METHODS

Longitudinal, observational study of mainstream schoolchildren comparing grade retention (GR) and learning disorders (LD) in students with vs. without TD between 2010 and 2014. Students with vs. without TD based on DSM-IV-TR criteria, or with vs. without GR and LD were compared in terms of comorbidities, school, and environmental characteristics. The association of TD with GR was analyzed using hazard ratios (HRs) with 95% CIs, and with LD using logistic regression analysis [Odds ratio (OR)].

RESULTS

Two hundred fifty-eight students were included (mean age 14.0 ± 1.71 years, 143 [55.4%] males). The incident rate for TD and GR was 2.6 and 3.3 per 100 persons-year, respectively. LD found in 21 (9.9%) students was associated with TD (OR 11.62, 95% CI 2.21-60.90, p = 0.004), and attention deficit hyperactivity disorder (ADHD; OR 6.63, 95% CI 1.55-28.37, p = 0.01). Low psychological support (HRs 12.79, 95% CI 3.39-48.17) and low sport participation (HRs 6.41, 95% CI 1.54-26.78) were risk factors for GR.

CONCLUSIONS

TD was associated with academic difficulties, namely, LD in conjunction with ADHD but not GR. The diagnosis of TD and comorbidities, and the initiation of proper treatment could have a favorable impact on school performance, and consequently on social development.

Clinical effectiveness and patient perspectives of different treatment strategies for tics in children and adolescents with Tourette syndrome: a systematic review and qualitative analysis

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental condition characterised by chronic motor and vocal tics affecting up to 1% of school-age children and young people and is associated with significant distress and psychosocial impairment.

OBJECTIVE

To conduct a systematic review of the benefits and risks of pharmacological, behavioural and physical interventions for tics in children and young people with TS (part 1) and to explore the experience of treatment and services from the perspective of young people with TS and their parents (part 2).

DATA SOURCES

For the systematic reviews (parts 1 and 2), mainstream bibliographic databases, The Cochrane Library, education, social care and grey literature databases were searched using subject headings and text words for tic* and Tourette* from database inception to January 2013.

REVIEW/RESEARCH METHODS

For part 1, randomised controlled trials and controlled before-and-after studies of pharmacological, behavioural or physical interventions in children or young people (aged < 18 years) with TS or chronic tic disorder were included. Mixed studies and studies in adults were considered as supporting evidence. Risk of bias associated with each study was evaluated using the Cochrane tool. When there was sufficient data, random-effects meta-analysis was used to synthesize the evidence and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. For part 2, qualitative studies and survey literature conducted in populations of children/young people with TS or their carers or in health professionals with experience of treating TS were included in the qualitative review. Results were synthesized narratively. In addition, a national parent/carer survey was conducted via the Tourettes Action website. Participants included parents of children and young people with TS aged under 18 years. Participants (young people with TS aged 10-17 years) for the in-depth interviews were recruited via a national survey and specialist Tourettes clinics in the UK.

RESULTS

For part 1, 70 studies were included in the quantitative systematic review. The evidence suggested that for treating tics in children and young people with TS, antipsychotic drugs [standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -1.08 to -0.41; n = 75] and noradrenergic agents [clonidine (Dixarit(®), Boehringer Ingelheim) and guanfacine: SMD -0.72, 95% CI -1.03 to -0.40; n = 164] are effective in the short term. There was little difference among antipsychotics in terms of benefits, but adverse effect profiles do differ. Habit reversal training (HRT)/comprehensive behavioural intervention for tics (CBIT) was also shown to be effective (SMD -0.64, 95% CI -0.99 to -0.29; n = 133). For part 2, 295 parents/carers of children and young people with TS contributed useable survey data. Forty young people with TS participated in in-depth interviews. Four studies were in the qualitative review. Key themes were difficulties in accessing specialist care and behavioural interventions, delay in diagnosis, importance of anxiety and emotional symptoms, lack of provision of information to schools and inadequate information regarding medication and adverse effects.

LIMITATIONS

The number and quality of clinical trials is low and this downgrades the strength of the evidence and conclusions.

CONCLUSIONS

Antipsychotics, noradrenergic agents and HRT/CBIT are effective in reducing tics in children and young people with TS. The balance of benefits and harms favours the most commonly used medications: risperidone (Risperdal(®), Janssen), clonidine and aripiprazole (Abilify(®), Otsuka). Larger and better-conducted trials addressing important clinical uncertainties are required. Further research is needed into widening access to behavioural interventions through use of technology including mobile applications ('apps') and video consultation.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002059.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

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.

Premonitory Awareness in Stuttering Scale (PAiS)

Anticipation of stuttering events in persistent developmental stuttering is a frequent but inadequately measured phenomenon that is of both theoretical and clinical importance. Here, we describe the development and preliminary testing of a German version of the Premonitory Awareness in Stuttering Scale (PAiS): a 12-item questionnaire assessing immediate and prospective anticipation of stuttering that was translated and adapted from the Premonitory Urge for Tics Scale (PUTS) (Woods, Piacentini, Himle, & Chang, 2005). After refining the preliminary PAiS scale in a pilot study, we administered a revised version to 21 adults who stutter (AWS) and 21 age, gender and education-matched control participants. Results demonstrated that the PAiS had good internal consistency and discriminated the two speaker groups very effectively, with AWS reporting anticipation of speech disruptions significantly more often than adults with typical speech. Correlations between the PAiS total score and both the objective and subjective measures of stuttering severity revealed that AWS with high PAiS scores produced fewer stuttered syllables. This is possibly because these individuals are better able to adaptively use these anticipatory sensations to modulate their speech. These results suggest that, with continued refinement, the PAiS has the potential to provide clinicians and researchers with a practical and psychometrically sound tool that can quantify how a given AWS anticipates upcoming stuttering events.

Investigating young people’s experiences of successful or helpful psychological interventions for tic disorders: An Interpretative Phenomenological Analysis study

There is emerging evidence for talking therapies in the treatment of tic disorders. This study explored experiences of young people who self-identified as having had a successful or helpful talking therapy, in order to understand the phenomenology, value and meaning of outcomes. The experiences of seven participants aged 10–17 years were described in semi-structured interviews and analysed using Interpretative Phenomenological Analysis. Themes included the challenging battle with tics and process of re-defining self-identity, making sense of and managing experiences, the value of control, and spectrum of positive change. The results highlighted valued outcomes that could be incorporated into clinical practice and future evaluation.

Provisional Tic Disorder: What to tell parents when their child first starts ticcing

The child with recent onset of tics is a common patient in a pediatrics or child neurology practice. If the child’s first tic was less than a year in the past, the diagnosis is usually Provisional Tic Disorder (PTD). Published reviews by experts reveal substantial consensus on prognosis in this situation: the tics will almost always disappear in a few months, having remained mild while they lasted. Surprisingly, however, the sparse existing data may not support these opinions.

PTD may have just as much importance for science as for clinical care. It provides an opportunity to prospectively observe the spontaneous remission of tics. Such prospective studies may aid identification of genes or biomarkers specifically associated with remission rather than onset of tics. A better understanding of tic remission may also suggest novel treatment strategies for Tourette syndrome, or may lead to secondary prevention of tic disorders.

This review summarizes the limited existing data on the epidemiology, phenomenology, and outcome of PTD, highlights areas in which prospective study is sorely needed, and proposes that tic disorders may completely remit much less often than is generally believed.

Increased risk of epilepsy in children with Tourette syndrome: A population-based case-control study

The association between epilepsy and Tourette syndrome has rarely been investigated. In this retrospective cohort study, we analyzed a dataset of 1,000,000 randomly sampled individuals from the Taiwan National Health Insurance Research Database to determine the risk of epilepsy in children with Tourette syndrome. The study cohort consisted of 1062 patients with Tourette syndrome aged ≤ 18 years, and the control group consisted of three times the number of age- and sex-matched patients without Tourette syndrome, who were insurants, from the same database during the same period. The Tourette syndrome group had an 18.38-fold increased risk of epilepsy than the control group [hazard ratio=18.38, 95% confidence interval (CI)=8.26-40.92; P<0.001]. Even after adjusting for the comorbidities, the risk of epilepsy in the Tourette syndrome group with comorbidities remained high (hazard ratio=16.27, 95% CI=6.26-18.46; P<0.001), indicating that the increased risk was not associated with comorbidities. This population-based retrospective cohort study provides the first and strong evidence that Tourette syndrome is associated with a higher risk of epilepsy. A close follow-up of children with Tourette syndrome for the development of epilepsy is warranted.

Lack of genetic association of 5-HTR2A 102 T/C and -1438A/G polymorphisms with Tourette syndrome in a family-based association study in a Chinese Han population

INTRODUCTION

Our purpose is to investigate whether polymorphisms of 102 T/C and -1438A/G in 5HTR2A are associated with Tourette syndrome (TS) in Chinese Han population.

METHODS

A total of 178 TS trios were recruited in this study. After the allelic and genotypic distributions of two polymorphisms were genotyped using polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP), we compared their genetic distributions with what is expected with Hardy-Weinberg to explore whether there might be an association of these polymorphisms with TS by haplotype relative risk (HRR) and transmission disequilibrium test (TDT) statistics.

RESULTS

Our results showed that no significant associations were found between the HTR2A 102 T/C and -1438A/G polymorphisms and TS (for HTR2A 102 T/C: TDT = 2.041, df = 1, P = 0.175; HRR = 1.468, χ(2)  = 1.905, P = 0.168, 95% confidence interval: 0.850-2.535; for HTR2A: -1438A/G, TDT = 0.093, df = 1, P = 0.819; HRR = 0.965, χ(2)  = 0.018, P = 0.894, 95% confidence interval: 0.574-1.624).

DISCUSSION

Our study suggested that the HTR2A 102T/C and -1438A/G polymorphisms may not be associated with susceptibility to TS, and thus do not play a major role in the development of TS in the Chinese Han population. However, these results need to be confirmed in a larger sample collected from different populations.

Tourette syndrome associated with attention deficit hyperactivity disorder: The impact of tics and psychopharmacological treatment options

Tourette syndrome (TS) is a neurodevelopmental disorder characterized by multiple chronic motor and vocal tics beginning in childhood. Several studies describe the association between TS and attention deficit hyperactivity disorder (ADHD). Fifty percent of children diagnosed with ADHD have comorbid tic disorder. ADHD related symptoms have been reported in 35% to 90% of children with TS. Since ADHD is the most prevalent comorbid condition with TS and those with concomitant TS and ADHD present with considerable psychosocial and behavioral impairments, it is essential for clinicians to be familiar with these diagnoses and their management. This paper highlights the association between treating ADHD with stimulants and the development of tic disorders. The two cases discussed underscore the fact that children with TS may present with ADHD symptomatology prior to the appearance of any TS related symptoms. Appropriate management of TS in a patient diagnosed with ADHD can lead to quality of life improvements and a reduction in psychosocial impairments.

Premonitory Urges in Patients with Gilles de la Tourette Syndrome: An Italian Translation and a 7-Year Follow-up

OBJECTIVE

Premonitory sensations or urges (PUs) are described as characteristic sensory phenomena preceding tics, which are often described as unpleasant. They occur in 90% of patients affected by Gilles de la Tourette Syndrome (GTS). They may be localized (around the area of tic) or generalized (covering a wide area of the body). The PUs can be measured by the Premonitory Urge for Tics Scale (PUTS). In this study we translated the PUTS scale into Italian and then assessed children and adolescents/young people (CYP) with GTS using the scale.

METHODS

GTS patients were assessed at the initial interview and after 7 years to evaluate the PUs, and the correlations of the PUTS scores with tic severity, severity of comorbid disorders (obsessive-compulsive disorder [OCD], attention-deficit/hyperactivity disorder [ADHD]), and a variety of coexisting psychopathologies.

RESULTS

A total of 95 patients were studied. We successfully translated the PUTS into Italian, and our results indicated that our translated version had good psychometric properties. Results demonstrated that the CYP had PUs at both interviews, but that older CYP were more consistent in reporting PUs than younger CYP (i.e., PUTS scores increased with age). We found no correlations between PUTS score and tic severity at either interview. We found a statistical significant correlation between PUTS score and obsessive-compulsive symptoms (OCS) at both interviews; Moreover both the PUTS and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) scores increased significantly, whereas the Yale Global Tic Severity Rating Scale (YGTSS) score decreased significantly. We found no relationships between PUTS scores and anxiety, depression, ADHD, and externalizing/internalizing behavioral scores.

CONCLUSIONS

Our results suggest the the Italian translation of the PUTS has good psychometric properties. Although both younger (<10 years of age) and older CYP (≤ 10 years of age) reported PUs, the scores at the initial interview were statistically significantly lower than at follow-up. Moreover, in CYP >10 years of age, the PUs correlated with obsessions and compulsions (CY-BOCS scores).

Serial pharmacological prescribing practices for tic management in Tourette syndrome

Pharmacological treatments for Tourette syndrome (TS) vary in efficacy between different patients. The evidence base is limited as even high quality controlled studies tend to be of relatively short duration which may lose relevance in clinical usage. Patients are frequently treated with serial agents in the search for efficacy and tolerability. The success of this strategy has not been previously documented. We examined 400 consecutive TS patients seen over a 10-year period, some with a longer prior history in other clinics; 255/400 (64%) were prescribed medication. We present this heterogeneous cohort in terms of the number of drugs they had tried, and as a proxy measure of some benefit of the last drug used, whether it had been prescribed under our supervision for ≥ 5 months. The most commonly prescribed medications were aripiprazole (64%), clonidine (40%), risperidone (30%) and sulpiride (29%) with changes in prescribing practises over the period examined. The number of different drugs tried were one (n = 155), two (n = 69), three (n = 36), four (n = 14), five (n = 15), six (n = 5), seven (n = 2) and eight (n = 1). The data illustrate the difficulty in drug treatment of tics and suggest that even after trials of several agents there is potential benefit in trying further options.

rs2043211 polymorphism in CARD8 is not associated with Tourette syndrome in a family-based association study in the Chinese Han population

BACKGROUND

Previous studies showed that postinfectious autoimmunity and immune deficiency played an important role in the pathogenesis of Tourette syndrome. CARD8 can suppress activity of NF-ΚB activated by inflammatory mediators.

OBJECTIVE

To study the association between the rs2043211 polymorphism in CARD8 and susceptibility to Tourette syndrome in Chinese Han population.

METHODS

We recruited 279 patients diagnosed with Tourette syndrome and their parents for the study. Genotyping for CARD8 rs2043211 single-nucleotide polymorphism was performed using predesigned TaqMan single-nucleotide polymorphism genotyping assay. The genetic contribution of this single-nucleotide polymorphism was evaluated using transmission disequilibrium test and haplotype relative risk and the haplotype-based haplotype relative risk.

RESULTS

The results of the allelic and genotypic distribution of rs2043211 polymorphism in CARD8 showed that both the Tourette syndrome patients group and the parents group are in Hardy-Weinberg equilibrium. No significant differences were observed in the mutant allele transmission (transmission disequilibrium test = 1.107, df = 1, p = 0.322). Results of haplotype relative risk analysis showed that no statistical significant difference was found in the genotypic frequency (AA/AT/TT) of Tourette syndrome patients passed from parents (haplotype relative risk = 1.152, χ(2 )= 0.494, p = 0.482, 95% CI = 0.777-1.708). Similarly, the analysis of haplotype-based haplotype relative risk was also not to support a statistically significant association in allelic frequency (A/T) of Tourette syndrome patients passed from parents (haplotype-based haplotype relative risk = 1.130, χ(2 )= 1.037, p = 0.308, 95% CI = 0.893-1.429).

CONCLUSION

Our results suggest CARD8 might not play a role in the pathogenesis of Tourette syndrome in Chinese Han population. However, the results still need to be tested in a larger sample and different populations.

Gilles de la Tourette syndrome in a cohort of deaf people

We present six patients with Gilles de la Tourette syndrome (TS) who are also deaf. TS has been observed previously, but rarely reported in deaf people, and to date, so called "unusual" phenomenology has been highlighted. TS occurs almost worldwide and in all cultures, and the clinical phenomenology is virtually identical. In our cohort of deaf patients (we suggest another culture) with TS, the phenomenology is the same as in hearing people, and as in all other cultures, with classic motor and vocal/phonic tics, as well as associated phenomena including echo-phenomena, pali-phenomena and rarer copro-phenomena. When "words" related to these phenomenon (e.g. echolalia, palilalia, coprolalia or mental coprolalia) are elicited in deaf people, they occur usually in British Sign Language (BSL): the more "basic" vocal/phonic tics such as throat clearing are the same phenomenologically as in hearing TS people. In our case series, there was a genetic predisposition to TS in all cases. We would argue that TS in deaf people is the same as TS in hearing people and in other cultures, highlighting the biological nature of the disorder.

The role of the autonomic nervous system in Tourette Syndrome

Tourette Syndrome (TS) is a neurodevelopmental disorder, consisting of multiple involuntary movements (motor tics) and one or more vocal (phonic) tics. It affects up to one percent of children worldwide, of whom about one third continue to experience symptoms into adulthood. The central neural mechanisms of tic generation are not clearly understood, however recent neuroimaging investigations suggest impaired cortico-striato-thalamo-cortical activity during motor control. In the current manuscript, we will tackle the relatively under-investigated role of the peripheral autonomic nervous system, and its central influences, on tic activity. There is emerging evidence that both sympathetic and parasympathetic nervous activity influences tic expression. Pharmacological treatments which act on sympathetic tone are often helpful: for example, Clonidine (an alpha-2 adrenoreceptor agonist) is often used as first choice medication for treating TS in children due to its good tolerability profile and potential usefulness for co-morbid attention-deficit and hyperactivity disorder. Clonidine suppresses sympathetic activity, reducing the triggering of motor tics. A general elevation of sympathetic tone is reported in patients with TS compared to healthy people, however this observation may reflect transient responses coupled to tic activity. Thus, the presence of autonomic impairments in patients with TS remains unclear. Effect of autonomic afferent input to cortico-striato-thalamo-cortical circuit will be discussed schematically. We additionally review how TS is affected by modulation of central autonomic control through biofeedback and Vagus Nerve Stimulation (VNS). Biofeedback training can enable a patient to gain voluntary control over covert physiological responses by making these responses explicit. Electrodermal biofeedback training to elicit a reduction in sympathetic tone has a demonstrated association with reduced tic frequency. VNS, achieved through an implanted device that gives pulsatile electrical stimulation to the vagus nerve, directly modulates afferent interoceptive signals. The potential efficacy of biofeedback/VNS in TS and the implications for understanding the underlying neural mechanisms of tics will be discussed.

The lived experiences of individuals with Tourette syndrome or tic disorders: a meta-synthesis of qualitative studies

There is a growing body of qualitative literature describing the lived experiences of people with tic disorders (TDs). The aim of this paper was to conduct a systematic review of this literature, synthesizing the perspectives of individuals on their experiences. Meta-synthesis methodology was utilized to review and draw together findings from 10 articles, from which key concepts were extracted, and over-arching themes generated. Six themes were identified to encompass the experience of TDs, including (1) cultural, semantic issues of the condition; (2) negative experiences in organizations and treatment; (3) the value and negative impact on interpersonal relationships; (4) personal identity in the constant presence of TDs; (5) concerns for the future; and (6) strategies to control and manage the observable presence of tics. Adaptive coping strategies were found to encompass continuous social adaptation, strategies to manage tics and social perceptions, self-acceptance, advocacy, and support from others. The results highlighted the significant role of social and cultural issues related to understanding and stigma, which underpinned many of the lived experiences. Implications for clinical practice in supporting individuals with TDs were also highlighted.

Trends in psychopharmacologic treatment of tic disorders in children and adolescents in Germany

Data on medical treatment of children and adolescents with tic disorders are scarce. This study examined the administrative prevalence of psychopharmacological prescriptions in this patient group in Germany. Data of the largest German health insurance fund were analysed. In outpatients aged 0-19 years with diagnosed tic disorder, psychotropic prescriptions were evaluated for the years 2006 and 2011. In 2011, the percentage of psychotropic prescriptions was slightly higher than in 2006 (21.2 vs. 18.6%). The highest prescription prevalence was found in Tourette syndrome (51.5 and 53.0%, respectively). ADHD drugs were most frequently prescribed, followed by antipsychotics. In 2011, prescriptions of second generation antipsychotics (SGA) were higher and prescriptions of first generation antipsychotics (FGA) lower than in 2006. Concerning prescribed antipsychotic substances, in 2011 risperidone prescriptions were higher and tiapride prescriptions lower. Paediatricians issued 37.4%, and child and adolescent psychiatrists issued 37.1% of psychotropic prescriptions. The FGA/SGA ratio was highest in GPs (1.25) and lowest in child and adolescent psychiatrists (0.96). From 2006 to 2011, there was only a slight increase in psychotropic prescriptions for children and adolescents with a diagnosis of tic disorder in Germany, which stands in contrast towards the significant increase in psychotropic prescriptions in other child and adolescent psychiatric disorders (e.g. ADHD). There were marked differences in treatment patterns by tic disorder subgroups, with Tourette syndrome patients receiving most frequently psychopharmacotherapy. Risperidone prescriptions increased, probably reflecting a switch in prescribing practice towards up-to-date treatment guidelines. In primary care physicians, dissemination of current tic disorder treatment guidelines might constitute an important educational goal.

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.

Population prevalence of Tourette syndrome: a systematic review and meta-analysis

The aim of this study was to refine the population prevalence estimate of Tourette Syndrome (TS) in children and to investigate potential sources of heterogeneity in previously published studies. A systematic review was conducted and all qualifying published studies of TS prevalence were examined. Extracted data were subjected to a random-effects meta-analysis weighted by sample size; meta-regressions were performed to examine covariates that have previously been proposed as potential sources of heterogeneity. Twenty-six articles met study inclusion criteria. Studies derived from clinically referred cases had prevalence estimates that were significantly lower than those derived from population-based samples (P = 0.004). Among the 21 population-based prevalence studies, the pooled TS population prevalence estimate was 0.52% (95% confidence interval CI: 0.32-0.85). In univariable meta-regression analysis, study sample size (P = 0.002) and study date (P = 0.03) were significant predictors of TS prevalence. In the final multivariable model including sample size, study date, age, and diagnostic criteria, only sample size (P < 0.001) and diagnostic criteria (omnibus P = 0.003; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [DSM-IV-TR]: P = 0.005) were independently associated with variation in TS population prevalence across studies. This study refines the population prevalence estimate of TS in children to be 0.3% to 0.9%. Study sample size, which is likely a proxy for case assessment method, and the use of DSM-IV-TR diagnostic criteria are the major sources of heterogeneity across studies. The true TS population prevalence rate is likely at the higher end of these estimates, given the methodological limitations of most studies. Further studies in large, well-characterized samples will be helpful to determine the burden of disease in the general population.

Tourette's: syndrome, disorder or spectrum? Classificatory challenges and an appraisal of the DSM criteria

The fifth version of the Diagnostic and statistical manual of mental disorders (DSM-5) was released in May 2013 after 14 years of development and almost two decades after the last edition DSM-IV was published in 1994. We review the DSM journey with regards to Tourette Syndrome from the original publication of DSM 1 in 1952 till date. In terms of changes in DSM 5, the major shift has come in the placement of Tourette Syndrome under the 'Neurodevelopmental Disorders' alongside other disorders with a developmental origin. This review provides an overview of the changes in DSM-5 highlighting key points for clinical practice and research along with a snap shot of the current use of DSM as a classificatory system in different parts of the world and suggestions for improving the subtyping and the diagnostic confidence.