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Sarchioto M, Frey J, Ganos C, Gilbert DL, Hartmann A, Hedderly T, Isaacs D, Malaty I, Martindale JM, Medina Escobar A, Müller-Vahl KR, Okun MS, Parnes M, Sarva H, Śmilowska K, Szejko N, Tomczak K, Worbe Y, Pringsheim T, Martino D. Diagnostic Criteria for Primary Tic Disorders: Time for Reappraisal. Mov Disord 2024; 39:1276-1281. [PMID: 38894500 DOI: 10.1002/mds.29868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- Marianna Sarchioto
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jessica Frey
- Rockefeller Neuroscience Institute, Department of Neurology, West Virginia University, Morgantown, West Virginia, USA
| | - Christos Ganos
- Department of Medicine, University of Toronto, UHN and UHN Foundation, Toronto, Ontario, Canada
| | - Donald L Gilbert
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Division of Neurology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Andreas Hartmann
- Centre de Référence National Maladie Rare 'Syndrome Gilles de la Tourette', DMU Neurosciences, AP-HP, Sorbonne Université, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Tammy Hedderly
- Department of Women and Children's Health, Evelina London Children's Hospital, Paediatric Neurosciences, GSTT and Kings College London, Faculty of Life Sciences and Medicine, London, United Kingdom
| | - David Isaacs
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Irene Malaty
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida Health, Gainesville, Florida, USA
| | - Jaclyn M Martindale
- Department of Neurology, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Alex Medina Escobar
- Division of Neurology, Moncton Interdisciplinary Neurodegenerative Diseases Clinic, Horizon Health Network, Fredericton, New Brunswick, Canada
| | - Kirsten R Müller-Vahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Michael S Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida Health, Gainesville, Florida, USA
| | - Mered Parnes
- Division of Pediatric Neurology and Developmental Neuroscience, Pediatric Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA
| | - Harini Sarva
- Department of Neurology, Weill Cornell Medicine, Parkinson's Disease and Movement Disorders Institute, New York, New York, USA
| | | | - Natalia Szejko
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Bioethics, Medical University of Warsaw, Warsaw, Poland
| | - Kinga Tomczak
- Department of Neurology, Harvard Medical School, Tic Disorders and Tourette Syndrome Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yulia Worbe
- Department of Clinical Neurophysiology, Sorbonne University, Paris Brain Institute - ICM, INserm CNRS and Saint-Antoine Hospital, Paris, France
| | - Tamara Pringsheim
- Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Davide Martino
- Department of Clinical Neurosciences, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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Orth L, Meeh J, Leiding D, Habel U, Neuner I, Sarkheil P. Aberrant Functional Connectivity of the Salience Network in Adult Patients with Tic Disorders: A Resting-State fMRI Study. eNeuro 2024; 11:ENEURO.0223-23.2024. [PMID: 38744491 PMCID: PMC11167695 DOI: 10.1523/eneuro.0223-23.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 12/27/2023] [Accepted: 02/26/2024] [Indexed: 05/16/2024] Open
Abstract
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.
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Affiliation(s)
- Linda Orth
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, 52074 Aachen, Germany
| | - Johanna Meeh
- Department of Psychiatry and Psychotherapy, University of Münster, 48149 Münster, Germany
| | - Delia Leiding
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, 52074 Aachen, Germany
| | - Ute Habel
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, 52074 Aachen, Germany
| | - Irene Neuner
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, 52074 Aachen, Germany
- Institute of Neuroscience and Medicine 4, INM-4, Forschungszentrum Jülich, 52428 Jülich, Germany
| | - Pegah Sarkheil
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, 52074 Aachen, Germany
- Department of Psychiatry and Psychotherapy, University of Münster, 48149 Münster, Germany
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Cavanna AE, Spini L, Ferrari S, Purpura G, Riva A, Nacinovich R, Seri S. Functional Tic-like Behaviors: From the COVID-19 Pandemic to the Post-Pandemic Era. Healthcare (Basel) 2024; 12:1106. [PMID: 38891181 PMCID: PMC11171709 DOI: 10.3390/healthcare12111106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/23/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
During the COVID-19 pandemic, there have been multiple reports about an unforeseen surge in adolescents and young adults exhibiting sudden onset functional tic-like behaviors. This phenomenon has been mainly associated with the female gender and occasionally after exposure to social media content featuring similar patterns of functional tic-like behaviors. A significant portion of these individuals have been directed to specialist clinics for movement disorders with initial misdiagnoses of late-onset refractory Tourette syndrome. Distinguishing between rapid onset functional tic-like behaviors and neurodevelopmental tics as part of Tourette syndrome can be challenging; however, the differential diagnosis is facilitated by focusing on specific clinical and demographic factors, which we have explored in a systematic literature review. Compared to neurodevelopmental tics, functional tic-like behaviors typically present with a more abrupt and intense manifestation of symptoms, onset at a later age, higher prevalence among females, inability to suppress tics, coexisting anxiety and depression, and sometimes a history of exposure to social media content portraying tic-like behaviors of a similar nature. This novel manifestation of a functional neurological disorder may thus be viewed as an emerging neuropsychiatric condition potentially triggered/exacerbated by the psychosocial repercussions of the COVID-19 crisis.
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Affiliation(s)
- Andrea Eugenio Cavanna
- Department of Neuropsychiatry, National Centre for Mental Health, BSMHFT and University of Birmingham, Birmingham B15 2FG, UK
- School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham B4 7ET, UK
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, London WC1E 6BT, UK
- Department of Child Neuropsychiatry, IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Laura Spini
- Department of Child Neuropsychiatry, IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Silvia Ferrari
- Department of Child Neuropsychiatry, IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Giulia Purpura
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Anna Riva
- Department of Child Neuropsychiatry, IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Renata Nacinovich
- Department of Child Neuropsychiatry, IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Stefano Seri
- School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham B4 7ET, UK
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Robert C, Weiblen R, Wagner-Altendorf TA, Paulus T, Müller-Vahl K, Münchau A, Krämer UM, Heldmann M, Roessner V, Münte TF. Slips of the tongue in patients with Gilles de la Tourette syndrome. Neurol Res Pract 2024; 6:25. [PMID: 38693574 PMCID: PMC11064284 DOI: 10.1186/s42466-024-00324-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/16/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Motor and vocal tics are the main symptom of Gilles de la Tourette-syndrome (GTS). A particular complex vocal tic comprises the utterance of swear words, termed coprolalia. Since taboo words are socially inappropriate, they are normally suppressed by people, which implies cognitive control processes. METHOD To investigate the control of the unintentional pronunciation of taboo words and the associated processes of conflict monitoring, we used the "Spoonerisms of Laboratory Induced Predisposition" (SLIP) paradigm. Participants read multiple inductor word pairs with the same phonemes, followed by pronouncing a target pair with inverse phonemes. This led to a conflict between two competing speech plans: the correct word pair and the word pair with inverted phonemes. Latter speech error, a spoonerism, could result in a neutral or taboo word. We investigated 19 patients with GTS and 23 typically developed controls (TDC) and measured participants' electroencephalography (EEG) during the SLIP task. RESULTS At the behavioral level less taboo than neutral word spoonerisms occurred in both groups without significant differences. Event-related brain potentials (ERP) revealed a difference between taboo and neutral word conditions in the GTS group at the midline electrodes in a time range of 250-400 ms after the speech prompt, which was not found in the TDC group. The extent of this effect depended on the number of inductor word pairs, suggesting an increasing level of cognitive control in the GTS group. CONCLUSION The differences between taboo and neutral word conditions in patients with GTS compared to TDC suggest an altered recruitment of cognitive control processes in GTS, likely enlisted to suppress taboo words.
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Affiliation(s)
- Carina Robert
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Center of Brain, Behavior and Metabolism, University of Lübeck, Marie-Curie-Straße, Building 66, 23562, Lübeck, Germany
| | - Ronja Weiblen
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Center of Brain, Behavior and Metabolism, University of Lübeck, Marie-Curie-Straße, Building 66, 23562, Lübeck, Germany
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | | | - Theresa Paulus
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Center of Brain, Behavior and Metabolism, University of Lübeck, Marie-Curie-Straße, Building 66, 23562, Lübeck, Germany
- Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany
| | - Kirsten Müller-Vahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Alexander Münchau
- Center of Brain, Behavior and Metabolism, University of Lübeck, Marie-Curie-Straße, Building 66, 23562, Lübeck, Germany
- Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany
| | - Ulrike M Krämer
- Center of Brain, Behavior and Metabolism, University of Lübeck, Marie-Curie-Straße, Building 66, 23562, Lübeck, Germany
- Institute of Medical Psychology, University of Lübeck, Lübeck, Germany
| | - Marcus Heldmann
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Center of Brain, Behavior and Metabolism, University of Lübeck, Marie-Curie-Straße, Building 66, 23562, Lübeck, Germany
- Department of Psychology, University of Lübeck, Lübeck, Germany
| | - Veit Roessner
- Department of Child and Adolescent Psychiatry, TU Dresden, Dresden, Germany
| | - Thomas F Münte
- Center of Brain, Behavior and Metabolism, University of Lübeck, Marie-Curie-Straße, Building 66, 23562, Lübeck, Germany.
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Nilles C, Martino D, Berg L, Fletcher J, Pringsheim T. What are the Key Phenomenological Clues to Diagnose Functional Tic-Like Behaviors in the Pandemic Era? Mov Disord Clin Pract 2024; 11:398-402. [PMID: 38269641 PMCID: PMC10982605 DOI: 10.1002/mdc3.13977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/23/2023] [Accepted: 12/13/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Functional tic-like behaviors (FTLBs) can be difficult to distinguish from tics. OBJECTIVES To describe the phenomenology of FTLBs in youth and assess the movements and vocalizations most suggestive of the diagnosis. METHODS We compared the phenomenology of tics between youth (<20 yr) with FTLBs and with primary tics from our Registry in Calgary, Canada. RESULTS Two hundred and thirty-six youths were included: 195 with primary tics (75% males; mean age: 10.8 yr) and 41 with FTLBs (98% females; 16.1 yr). In the bivariate models, FTLBs were most associated with copropraxia (OR = 15.5), saying words (OR = 14.5), coprolalia (OR = 13.1), popping (OR = 11.0), whistling (OR = 9.8), simple head movements (OR = 8.6), and self-injurious behaviors (OR = 6.9). In the multivariable model, FTLBs were still associated with saying words (OR = 13.5) and simple head movements (OR = 6.3). Only 12.2% of youth with FTLBs had throat clearing tics (OR = 0.2). CONCLUSIONS This study shall help physicians diagnose youth with FTLBs according to the presence/association of specific movements and vocalizations.
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Affiliation(s)
- Christelle Nilles
- Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health SciencesUniversity of CalgaryCalgaryABCanada
- Neurology DepartmentHôpital Fondation Adolphe de RothschildParisFrance
| | - Davide Martino
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryABCanada
- Hotchkiss Brain Institute, University of CalgaryCalgaryABCanada
- Mathison Centre for Mental Health Research and EducationCalgaryABCanada
| | - Lindsay Berg
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryABCanada
| | - Julian Fletcher
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryABCanada
| | - Tamara Pringsheim
- Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health SciencesUniversity of CalgaryCalgaryABCanada
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryABCanada
- Hotchkiss Brain Institute, University of CalgaryCalgaryABCanada
- Mathison Centre for Mental Health Research and EducationCalgaryABCanada
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Müller‐Vahl KR, Pisarenko A, Fremer C, Haas M, Jakubovski E, Szejko N. Functional Tic-Like Behaviors: A Common Comorbidity in Patients with Tourette Syndrome. Mov Disord Clin Pract 2024; 11:227-237. [PMID: 38468554 PMCID: PMC10928340 DOI: 10.1002/mdc3.13932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 09/24/2023] [Accepted: 11/07/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Comorbid functional tic-like behaviors (FTB) have been described only rarely in patients with Tourette syndrome (TS). OBJECTIVES We present the first large sample of patients suffering from TS and FTB to raise awareness of this clinical presentation and to guide how to differentiate one from the other. METHODS We analyzed clinical data of 71 patients (n = 27 [38.0%] female, mean age: 21.5, range: 11-55) with TS + FTB. RESULTS In the majority of patients, FTB started abruptly on average 15 years after tic onset with "treatment-resistant" complex movements and ("coprophenomena-like") vocalizations preceded by timely related psychological stressors. Psychological evaluation revealed evidence for internal conflicts (79%), emotional dysregulation (56%), and maintaining factors (70%). About one third of patients had a positive history for further medically unexplained symptoms. Compared to a large TS sample (n = 1032), patients with TS + FTB were more likely to be female, and presented significantly more common with "coprophenomena-like" symptoms, atypical influential factors, atypical descriptions of premonitory sensations, and higher rates of comorbid obsessive-compulsive disorder and "self-injurious" behavior. CONCLUSIONS Based on our data it can be assumed that FTB is a common comorbidity in TS, similar to functional overlay in other movement disorders and epilepsy. Before classifying a patient as suffering from treatment-resistant TS, FTB should be ruled out.
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Affiliation(s)
- Kirsten R. Müller‐Vahl
- Clinic of Psychiatry, Social Psychiatry and PsychotherapyHannover Medical SchoolHannoverGermany
| | - Anna Pisarenko
- Clinic of Psychiatry, Social Psychiatry and PsychotherapyHannover Medical SchoolHannoverGermany
| | - Carolin Fremer
- Clinic of Psychiatry, Social Psychiatry and PsychotherapyHannover Medical SchoolHannoverGermany
| | - Martina Haas
- Clinic of Psychiatry, Social Psychiatry and PsychotherapyHannover Medical SchoolHannoverGermany
| | - Ewgeni Jakubovski
- Clinic of Psychiatry, Social Psychiatry and PsychotherapyHannover Medical SchoolHannoverGermany
| | - Natalia Szejko
- Clinic of Psychiatry, Social Psychiatry and PsychotherapyHannover Medical SchoolHannoverGermany
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada
- Department of BioethicsMedical University of WarsawWarsawPoland
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Fremer C, Szejko N, Pisarenko A, Haas M, Laudenbach L, Wegener C, Müller-Vahl KR. What distinguishes patients with mass social media-induced illness presenting with Tourette-like behavior from those with Tourette syndrome? Results of a prospective cohort study. Eur Arch Psychiatry Clin Neurosci 2024; 274:227-233. [PMID: 37209130 PMCID: PMC10787001 DOI: 10.1007/s00406-023-01603-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/29/2023] [Indexed: 05/22/2023]
Abstract
Since 2019, a global increase in patients presenting with functional Tourette-like behaviors (FTB) has been observed. This has been related to the exposure of tic-related content in social media, although other factors seem to further fuel this phenomenon. Recently, we, therefore, proposed the term mass social media-induced illness (MSMI) as, in our opinion, this phenomenon constitutes a new type of mass sociogenic illness (MSI) that is in contrast to all recent outbreaks spread solely via social media. In accordance with this hypothesis, we were able to identify the host of the German YouTube channel "Gewitter im Kopf" ("Thunderstorm in the brain") as the initial virtual index case. The purpose of this paper is to present clinical characteristics of a sample of 32 patients diagnosed with MSMI-FTB compared to a large sample of patients with Tourette syndrome (TS) and other chronic tic disorders (CTD) (n = 1032) from the same center in Germany indicating clinical factors helpful to distinguish between tics in TS/CTD and MSMI-FTB. Our main findings were: in patients with MSMI-FTB compared to those with TS/CTD we found (i) a significantly higher age at onset, (ii) a significantly higher rate of females, (iii) a significantly higher rate of obscene and socially inappropriate symptoms, (iv) a significantly lower rate of comorbid ADHD, and (v) a significantly lower rate of OCD/OCB. In contrast, rates of comorbid anxiety and depression as well as reported frequencies of premonitory urges/sensations and suppressibility of symptoms did not differ between groups.
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Affiliation(s)
- Carolin Fremer
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Natalia Szejko
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
- Department of Bioethics, Medical University of Warsaw, Warsaw, Poland
| | - Anna Pisarenko
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Martina Haas
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Luise Laudenbach
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Claudia Wegener
- Department of Audiovisual Media Studies, Film University Babelsberg, Potsdam, Germany
| | - Kirsten R Müller-Vahl
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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Maxwell A, Zouki JJ, Eapen V. Integrated cognitive behavioral intervention for functional tics (I-CBiT): case reports and treatment formulation. Front Pediatr 2023; 11:1265123. [PMID: 38034832 PMCID: PMC10687404 DOI: 10.3389/fped.2023.1265123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction The onset of the COVID-19 pandemic saw a global surge in functional tic-like behaviors (FTLBs). FTLBs are unique from primary tic disorders. They are thought to manifest through a complex interplay between environmental and personal factors, including the stress-arousal system, and are characterized by their sudden and explosive onset. Accordingly, common interventions for tic disorders show limited efficacy in this population. We present an Integrated Cognitive Behavioral Intervention for Functional Tics (I-CBiT) that uses an urge acceptance model to manage tics and related stress and anxiety. Methods We describe the treatment outcomes of eight young people presenting with new and sudden onset FTLBs who underwent I-CBiT, which integrates traditional behavioral tic interventions with third-wave cognitive behavioral therapies. All cases completed the three-phase intervention involving core components of psychoeducation, exposure and response prevention with urge acceptance, sensory grounding strategies, and cognitive behavioral intervention targeting the stress-arousal system. Tic severity and impairment were assessed prior to treatment and at completion. Results All cases showed a significant reduction in tic severity post I-CBiT and an improvement in overall daily living function. These cases highlight the role of urge acceptance in managing both tic urges and the underlying stress-arousal system to bring about long-term change. Conclusion We demonstrated the efficacy of I-CBiT for managing FTLBs. Our findings illustrate the importance of treating underlying stress and anxiety in this population and, therefore, a need for greater interaction between multidisciplinary services in managing FTLBs to comprehensively cover the varied symptom presentations linked to thoughts, emotions, bodily sensations, and stress responses.
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Affiliation(s)
- Amanda Maxwell
- Discipline of Psychiatry and Mental Health, UNSW School of Clinical Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Jade-Jocelyne Zouki
- Centre for Social and Early Emotional Development and School of Psychology, Deakin University, Geelong, VIC, Australia
| | - Valsamma Eapen
- Discipline of Psychiatry and Mental Health, UNSW School of Clinical Medicine, University of New South Wales, Kensington, NSW, Australia
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Rigas A, Mainka T, Pringsheim T, Münchau A, Malaty I, Worbe Y, Cavanna AE, Lees AJ, Lang AE, Martino D, Ganos C. Distinguishing functional from primary tics: a study of expert video assessments. J Neurol Neurosurg Psychiatry 2023; 94:751-756. [PMID: 37169545 PMCID: PMC10447361 DOI: 10.1136/jnnp-2022-330822] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/30/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Reliably applied criteria to differentiate functional from primary tics are lacking. In the absence of biological markers, the development of new diagnostic criteria to assist clinicians is predicated on expert judgement and consensus. This study examines the level of diagnostic agreement of experts in tic disorders using video footage and clinical descriptions. METHODS Using a two-part survey, eight experts in the diagnosis and management of tics were first asked to study 24 case videos of adults with primary tics, functional tics or both and to select a corresponding diagnosis. In the second part of the survey, additional clinical information was provided, and the diagnosis was then reconsidered. Inter-rater agreement was measured using Fleiss' kappa. In both study parts, the factors which influenced diagnostic decision-making and overall diagnostic confidence were reviewed. RESULTS Based on phenomenology alone, the diagnostic agreement among the expert raters was only fair for the pooled diagnoses (κ=0.21) as well as specifically for functional (κ=0.26) and primary tics (κ=0.24). Additional clinical information increased overall diagnostic agreement to moderate (κ=0.51) for both functional (κ=0.6) and primary tics (κ=0.57). The main factors informing diagnosis were tic semiology, age at tic onset, presence of premonitory urges, tic suppressibility, the temporal latency between tic onset and peak severity, precipitants and tic triggers and changes in the overall phenotypic presentation. CONCLUSIONS This study confirmed that in the absence of clinical information, the diagnostic distinction between primary and functional tics is often difficult, even for expert clinicians.
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Affiliation(s)
- Antigony Rigas
- Department of Neurology, Charité Medical Faculty Berlin, Berlin, Germany
| | - Tina Mainka
- Department of Neurology, Charité Medical Faculty Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Tamara Pringsheim
- Mathison Centre for Mental Health Research and Education, Calgary, Alberta, Canada
- Department of Clinical Neurosciences & Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Psychiatry, Pediatrics, Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alexander Münchau
- Institute of Systems Motor Science, Center of Brain, Behavior and Metabolism, Universität zu Lübeck, Lübeck, Germany
| | - Irene Malaty
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, University of Florida, USA
| | - Yulia Worbe
- ICM, Inserm, CNRS, Department of Neurophysiology, Hôpital Saint Antoine (DMU 6), AP-HP, Sorbonne University, Paris, France
| | - Andrea E Cavanna
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, UK
- School of Life and Health Sciences, Aston University, Birmingham, UK
- University College London and Institute of Neurology, London, UK
- Department of Child Neuropsychiatry, University of Milano-Bicocca, Milan, Italy
| | - Andrew John Lees
- Reta Lila Weston Institute of Neurological Studies, Institute of Neurology University College London, London, UK
| | - Anthony E Lang
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Davide Martino
- Mathison Centre for Mental Health Research and Education, Calgary, Alberta, Canada
- Department of Clinical Neurosciences & Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christos Ganos
- Department of Neurology, Charité Medical Faculty Berlin, Berlin, Germany
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10
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Arbuckle AL, Bihun EC, Schlaggar BL, Black KJ. Functional tic-like presentations differ strikingly from Provisional Tic Disorder. F1000Res 2023; 11:1566. [PMID: 37224324 PMCID: PMC10186060 DOI: 10.12688/f1000research.129252.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/26/2023] Open
Abstract
Background: Recent years have seen a dramatic increase in new "tic" cases in teens and young adults. These individuals often present with fulminant onset of symptoms not commonly seen in Tourette syndrome (TS) and are often diagnosed with Functional Neurological Symptom Disorder (FND-tic). However, some authors have questioned whether this illness truly differs from typical Provisional Tic Disorder (PTD) and TS. Previous studies have compared FND-tic, usually a few months after symptom onset, to patients with TS, usually years after symptom onset. We sought to test whether the presenting symptoms of FND-tic differ substantially from those in patients at a similar duration of symptoms who are later diagnosed with TS. Methods: This comparative study examines clinical features summarized from published reports of FND-tic with novel data from a longitudinal study of PTD. This study came from a referral center for TS and tic disorders and included 89 children with tics whose first tic occurred a median of 3.6 months earlier, nearly all of whom were diagnosed with a chronic tic disorder at follow-up. Specifically, we examine clinical features identified in a recent literature review as supporting a diagnosis of FND-tic, including symptom characteristics, course, severity and comorbidity. Results: Several clinical features dramatically distinguish the patients diagnosed with FND-tic from those diagnosed with typical PTD. For example, coprophenomena are reported at or shortly after symptom onset in over half of FND-tic patients, whereas even several months after onset, coprophenomena had occurred in only 1 of 89 children with PTD. Six clinical features each have a positive predictive value over 90% for FND-tic diagnosis if prior probability is 50%. Conclusions: These new data provide strong evidence supporting the diagnostic validity of FND-tic as distinct from TS.
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Affiliation(s)
- Amanda L. Arbuckle
- Department of Psychiatry, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, 63110, USA
| | - Emily C. Bihun
- Department of Psychiatry, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, 63110, USA
| | - Bradley L. Schlaggar
- Department of Pediatrics, Johns Hopkins Medicine, Baltimore, MD, 21287, USA
- Department of Neurology, Johns Hopkins Medicine, Baltimore, Maryland, 21287, USA
- Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA
| | - Kevin J. Black
- Department of Psychiatry, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, 63110, USA
- Department of Neurology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, 63110, USA
- Department of Neuroscience, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, 63110, USA
- Department of Radiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, 63110, USA
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11
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Okkels KB, Skov L, Klansø S, Aaslet L, Grejsen J, Reenberg A, Sørensen CB, Debes NMMM. Increased Number of Functional Tics Seen in Danish Adolescents during the COVID-19 Pandemic. Neuropediatrics 2023; 54:113-119. [PMID: 36417931 DOI: 10.1055/a-1985-6862] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Global increase in functional tics in adolescents has been observed. Differentiating functional from classic tics is important since pathophysiology and treatment differ. We investigated possible triggers for development of functional tics and discuss the possible role of the coronavirus disease 2019 (COVID-19) pandemic and social media exposure in cases of functional tics seen during this period. Moreover, the treatment, and its efficacy is discussed. METHODS Medical records of 28 Danish adolescents diagnosed with functional tics at the National Tourette Clinic, Department of Pediatrics, Herlev University Hospital, Denmark, from May 2020 to June 2021 have been retrospectively reviewed. Descriptive statistical analyses were used to analyze the data. MAIN FINDINGS A total of 28 patients diagnosed with functional tics were included, 96.4% girls and 3.6% boys, mean age 14.4 years. Tic phenomenology differed from classic tics with more complex tics and no rostrocaudal progression. Note that 69.2% reported harmful tics. Also, 78.6% had trauma/precipitating event and 40% denounced lockdown related to the COVID-19 pandemic as trigger, both prior to onset of functional tics. Note that 60.7% reported psychiatric symptoms/diagnoses, 42.9% had a first-degree family member with psychiatric symptoms/diagnoses, and 96.4% were exposed to tics on social media prior to onset. Treatment consisted of psychoeducation, elements from cognitive behavioral therapy, and focus on psychiatric symptoms. All patients responded to the treatment. CONCLUSION The vulnerability of the adolescents is characteristic. Treatment strategy has shown immediate positive effect. Consequences of the COVID-19 pandemic in combination with exposure to tics on social media could be part of the cause for the increase in number of functional tics.
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Affiliation(s)
- Kirstine Birkebæk Okkels
- Department of Pediatrics, The National Tourette Clinic, Herlev University Hospital, Herlev, Denmark
| | - Liselotte Skov
- Department of Pediatrics, The National Tourette Clinic, Herlev University Hospital, Herlev, Denmark
| | - Susanne Klansø
- Department of Pediatrics, The National Tourette Clinic, Herlev University Hospital, Herlev, Denmark
| | - Lone Aaslet
- Department of Pediatrics, The National Tourette Clinic, Herlev University Hospital, Herlev, Denmark
| | - Judy Grejsen
- Department of Pediatrics, The National Tourette Clinic, Herlev University Hospital, Herlev, Denmark
| | - Annika Reenberg
- Department of Pediatrics, The National Tourette Clinic, Herlev University Hospital, Herlev, Denmark
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12
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Frey J, Black KJ, Malaty IA. TikTok Tourette's: Are We Witnessing a Rise in Functional Tic-Like Behavior Driven by Adolescent Social Media Use? Psychol Res Behav Manag 2022; 15:3575-3585. [PMID: 36505669 PMCID: PMC9733629 DOI: 10.2147/prbm.s359977] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/19/2022] [Indexed: 12/12/2022] Open
Abstract
Perceptions of Tourette syndrome (TS) and tic disorders are often driven by social media. During the COVID-19 pandemic, social media consumption greatly increased, particularly in the adolescent population. In parallel with increased social media consumption, there has also been an increase in tic severity and functional tic-like behavior (FTLB). Given that many of the tic videos posted on social media are misleading, perpetuate false beliefs about TS, or reinforce tic-like behaviors, there is increasing concern that these videos are driving the rapid increase in FTLBs. Several studies have reviewed newly presenting cases of FTLB and have found shared characteristics, including that a higher proportion of affected individuals are female, there is a low proportion with a history of childhood or family tics, and symptom onset is typically acute and develops in the teenage years. In addition, the quality of the tics seen in association with FTLB mirrors many of the tics seen on popular social media channels, with higher rates of coprophenomena, tic attacks, and involvement of the trunk and extremities than is seen with typical tics. FTLBs are likely a specific subgroup of functional tics largely influenced by the portrayal of and growing popularity of functional tics posted on social media during the COVID-19 pandemic. However, several factors, including increased anxiety, social isolation, and social media use in general during the pandemic are likely also contributing factors to the surge of FTLBs seen recently. In this era of increased social media consumption, it will become increasingly important for clinicians to educate patients about where and how medical information is spread, to ensure the best possible diagnosis, treatment, and outcomes for patients.
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Affiliation(s)
- Jessica Frey
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA,Correspondence: Jessica Frey, Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26505, USA, Tel +1 304-298-6127, Fax +1 304 598 6442, Email
| | - Kevin J Black
- Departments of Psychiatry, Neurology, Radiology, and Neuroscience, Washington University in St. Louis, St. Louis, MO, USA
| | - Irene A Malaty
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
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13
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Malaty IA, Anderson S, Bennett SM, Budman CL, Coffey BJ, Coffman KA, Greenberg E, McGuire JF, Müller-Vahl KR, Okun MS, Quezada J, Robichaux-Viehoever A, Black KJ. Diagnosis and Management of Functional Tic-Like Phenomena. J Clin Med 2022; 11:6470. [PMID: 36362696 PMCID: PMC9656241 DOI: 10.3390/jcm11216470] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 08/31/2023] Open
Abstract
Over the past 3 years, a global phenomenon has emerged characterized by the sudden onset and frequently rapid escalation of tics and tic-like movements and phonations. These symptoms have occurred not only in youth known to have tics or Tourette syndrome (TS), but also, and more notably, in youth with no prior history of tics. The Tourette Association of America (TAA) convened an international, multidisciplinary working group to better understand this apparent presentation of functional neurological disorder (FND) and its relationship to TS. Here, we review and summarize the literature relevant to distinguish the two, with recommendations to clinicians for diagnosis and management. Finally, we highlight areas for future emphasis and research.
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Affiliation(s)
- Irene A. Malaty
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL 32608, USA
| | | | - Shannon M. Bennett
- Department of Psychiatry, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY 10065, USA
| | - Cathy L. Budman
- Department of Psychiatry, Northwell Health, Zucker School of Medicine, Hofstra/Northwell, Uniondale, NY 11549, USA
| | - Barbara J. Coffey
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Keith A. Coffman
- Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO 64108, USA
| | - Erica Greenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02129, USA
| | - Joseph F. McGuire
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Kirsten R. Müller-Vahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School (MHH), 30625 Hannover, Germany
| | - Michael S. Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL 32608, USA
| | - Julio Quezada
- Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO 64108, USA
| | | | - Kevin J. Black
- Departments of Psychiatry, Neurology, Radiology and Neuroscience, Washington University in St. Louis, 660 S. Euclid Ave., St. Louis, MO 63110, USA
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14
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van der Veen S, Caviness JN, Dreissen YE, Ganos C, Ibrahim A, Koelman JH, Stefani A, Tijssen MA. Myoclonus and other jerky movement disorders. Clin Neurophysiol Pract 2022; 7:285-316. [PMID: 36324989 PMCID: PMC9619152 DOI: 10.1016/j.cnp.2022.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/29/2022] [Accepted: 09/11/2022] [Indexed: 11/27/2022] Open
Abstract
Myoclonus and other jerky movements form a large heterogeneous group of disorders. Clinical neurophysiology studies can have an important contribution to support diagnosis but also to gain insight in the pathophysiology of different kind of jerks. This review focuses on myoclonus, tics, startle disorders, restless legs syndrome, and periodic leg movements during sleep. Myoclonus is defined as brief, shock-like movements, and subtypes can be classified based the anatomical origin. Both the clinical phenotype and the neurophysiological tests support this classification: cortical, cortical-subcortical, subcortical/non-segmental, segmental, peripheral, and functional jerks. The most important techniques used are polymyography and the combination of electromyography-electroencephalography focused on jerk-locked back-averaging, cortico-muscular coherence, and the Bereitschaftspotential. Clinically, the differential diagnosis of myoclonus includes tics, and this diagnosis is mainly based on the history with premonitory urges and the ability to suppress the tic. Electrophysiological tests are mainly applied in a research setting and include the Bereitschaftspotential, local field potentials, transcranial magnetic stimulation, and pre-pulse inhibition. Jerks due to a startling stimulus form the group of startle syndromes. This group includes disorders with an exaggerated startle reflex, such as hyperekplexia and stiff person syndrome, but also neuropsychiatric and stimulus-induced disorders. For these disorders polymyography combined with a startling stimulus can be useful to determine the pattern of muscle activation and thus the diagnosis. Assessment of symptoms in restless legs syndrome and periodic leg movements during sleep can be performed with different validated scoring criteria with the help of electromyography.
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Affiliation(s)
- Sterre van der Veen
- Department of Neurology, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, The Netherlands,Expertise Centre Movement Disorders Groningen, University Medical Centre Groningen (UMCG), Groningen, The Netherlands
| | - John N. Caviness
- Department of Neurology, Mayo Clinic Arizona, Movement Neurophysiology Laboratory, Scottsdale, AZ, USA
| | - Yasmine E.M. Dreissen
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Christos Ganos
- Movement Disorders and Neuromodulation Unit, Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Abubaker Ibrahim
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes H.T.M. Koelman
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Ambra Stefani
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marina A.J. Tijssen
- Department of Neurology, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, The Netherlands,Expertise Centre Movement Disorders Groningen, University Medical Centre Groningen (UMCG), Groningen, The Netherlands,Corresponding author at: Department of Neurology, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 30.001, 9700 RB Groningen, The Netherlands.
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15
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Butler M, Seynaeve M, Bradley-Westguard A, Bao J, Crawshaw A, Pick S, Edwards M, Nicholson T, Rucker J. Views on Using Psychoactive Substances to Self-Manage Functional Neurological Disorder: Online Patient Survey Results. J Neuropsychiatry Clin Neurosci 2022; 35:77-85. [PMID: 35578800 DOI: 10.1176/appi.neuropsych.21080213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective: Functional neurological disorder (FND) causes a high burden of disability and distress. Although it is a common disorder, there is a pressing need for improved access to evidence-based treatments. With difficulties in finding effective treatment, some people with FND may seek alternative means of symptom relief, such as legal and illicit psychoactive substances, although the prevalence and nature of such self-management strategies are currently unclear. Additionally, psychoactive substances may represent novel treatment research opportunities, particularly for those with suboptimal improvement. The investigators examined the use of self-management techniques, as well as perspectives on novel therapies, in this patient population. Methods: An online survey was created to assess self-management strategies and views on novel treatments for FND, including psychedelic therapy. The survey was accessible for 1 month, and respondents were recruited internationally through social media and patient groups. A total of 1,048 respondents from 16 countries completed the survey. Results: Almost half (46%) of 980 respondents reported having tried legal psychoactive substances for the management of their FND symptoms and, on average, nicotine, alcohol, and cannabidiol were reported as modestly effective. Additionally, 15% of respondents reported having used illicit substances, mostly cannabis, to manage FND, with the majority reporting moderate effectiveness and experiencing no or minimal physical (90%) and psychological (95%) sequelae. Many respondents (46%) reported that they would be willing to try medically supervised psychedelic therapy (with 19% of respondents ambivalent) if it were found to be safe and effective. Conclusions: Many people with FND seek alternative means of symptom management outside usual medical care, including legal and illicit psychoactive substances. Further research exploring novel treatment options, such as psychedelics, in FND may be warranted.
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Affiliation(s)
- Matthew Butler
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London (Butler, Pick, Nicholson); Institute of Psychiatry, Psychology and Neuroscience, King's College London (Seynaeve, Bao, Rucker); independent patient researcher (Bradley-Westguard); National Health Service Foundation Trust (Crawshaw) and Department of Neurology (Edwards), St. George's University Hospitals, London; Institute of Molecular and Clinical Sciences, St. George's University of London (Crawshaw, Edwards); and Sobell Department of Motor Neurosciences and Movement Disorders, Queen Square Institute of Neurology, University College London (Edwards)
| | - Mathieu Seynaeve
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London (Butler, Pick, Nicholson); Institute of Psychiatry, Psychology and Neuroscience, King's College London (Seynaeve, Bao, Rucker); independent patient researcher (Bradley-Westguard); National Health Service Foundation Trust (Crawshaw) and Department of Neurology (Edwards), St. George's University Hospitals, London; Institute of Molecular and Clinical Sciences, St. George's University of London (Crawshaw, Edwards); and Sobell Department of Motor Neurosciences and Movement Disorders, Queen Square Institute of Neurology, University College London (Edwards)
| | - Abigail Bradley-Westguard
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London (Butler, Pick, Nicholson); Institute of Psychiatry, Psychology and Neuroscience, King's College London (Seynaeve, Bao, Rucker); independent patient researcher (Bradley-Westguard); National Health Service Foundation Trust (Crawshaw) and Department of Neurology (Edwards), St. George's University Hospitals, London; Institute of Molecular and Clinical Sciences, St. George's University of London (Crawshaw, Edwards); and Sobell Department of Motor Neurosciences and Movement Disorders, Queen Square Institute of Neurology, University College London (Edwards)
| | - Jianan Bao
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London (Butler, Pick, Nicholson); Institute of Psychiatry, Psychology and Neuroscience, King's College London (Seynaeve, Bao, Rucker); independent patient researcher (Bradley-Westguard); National Health Service Foundation Trust (Crawshaw) and Department of Neurology (Edwards), St. George's University Hospitals, London; Institute of Molecular and Clinical Sciences, St. George's University of London (Crawshaw, Edwards); and Sobell Department of Motor Neurosciences and Movement Disorders, Queen Square Institute of Neurology, University College London (Edwards)
| | - Ania Crawshaw
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London (Butler, Pick, Nicholson); Institute of Psychiatry, Psychology and Neuroscience, King's College London (Seynaeve, Bao, Rucker); independent patient researcher (Bradley-Westguard); National Health Service Foundation Trust (Crawshaw) and Department of Neurology (Edwards), St. George's University Hospitals, London; Institute of Molecular and Clinical Sciences, St. George's University of London (Crawshaw, Edwards); and Sobell Department of Motor Neurosciences and Movement Disorders, Queen Square Institute of Neurology, University College London (Edwards)
| | - Susannah Pick
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London (Butler, Pick, Nicholson); Institute of Psychiatry, Psychology and Neuroscience, King's College London (Seynaeve, Bao, Rucker); independent patient researcher (Bradley-Westguard); National Health Service Foundation Trust (Crawshaw) and Department of Neurology (Edwards), St. George's University Hospitals, London; Institute of Molecular and Clinical Sciences, St. George's University of London (Crawshaw, Edwards); and Sobell Department of Motor Neurosciences and Movement Disorders, Queen Square Institute of Neurology, University College London (Edwards)
| | - Mark Edwards
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London (Butler, Pick, Nicholson); Institute of Psychiatry, Psychology and Neuroscience, King's College London (Seynaeve, Bao, Rucker); independent patient researcher (Bradley-Westguard); National Health Service Foundation Trust (Crawshaw) and Department of Neurology (Edwards), St. George's University Hospitals, London; Institute of Molecular and Clinical Sciences, St. George's University of London (Crawshaw, Edwards); and Sobell Department of Motor Neurosciences and Movement Disorders, Queen Square Institute of Neurology, University College London (Edwards)
| | - Timothy Nicholson
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London (Butler, Pick, Nicholson); Institute of Psychiatry, Psychology and Neuroscience, King's College London (Seynaeve, Bao, Rucker); independent patient researcher (Bradley-Westguard); National Health Service Foundation Trust (Crawshaw) and Department of Neurology (Edwards), St. George's University Hospitals, London; Institute of Molecular and Clinical Sciences, St. George's University of London (Crawshaw, Edwards); and Sobell Department of Motor Neurosciences and Movement Disorders, Queen Square Institute of Neurology, University College London (Edwards)
| | - James Rucker
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London (Butler, Pick, Nicholson); Institute of Psychiatry, Psychology and Neuroscience, King's College London (Seynaeve, Bao, Rucker); independent patient researcher (Bradley-Westguard); National Health Service Foundation Trust (Crawshaw) and Department of Neurology (Edwards), St. George's University Hospitals, London; Institute of Molecular and Clinical Sciences, St. George's University of London (Crawshaw, Edwards); and Sobell Department of Motor Neurosciences and Movement Disorders, Queen Square Institute of Neurology, University College London (Edwards)
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16
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Zea Vera A, Bruce A, Garris J, Tochen L, Bhatia P, Lehman RK, Lopez W, Wu SW, Gilbert DL. The Phenomenology of Tics and Tic-Like Behavior in TikTok. Pediatr Neurol 2022; 130:14-20. [PMID: 35303587 DOI: 10.1016/j.pediatrneurol.2022.02.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/06/2022] [Accepted: 02/20/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Pediatricians and pediatric subspecialists worldwide have reported a marked increase in functional (conversion) disorders with tic-like behaviors during the COVID-19 pandemic. These patients often report frequent viewing of Tourette syndrome (TS) TikTok videos, suggesting disease modeling. We aimed to evaluate tic phenomenology in videos posted on TikTok. METHODS The 100 most-viewed videos under #tourettes in TikTok were randomly assigned to two of three primary reviewers (<2 years independent practice), all pediatric neurologists specializing in movement disorders, for extraction and classification of tic phenomenology. Initial disagreements were solved by consensus. If not resolved, one of five senior reviewers (>2 years independent pediatric movement disorder practice) served as a tiebreaker. In addition, two primary and one senior reviewer rated each video on a Likert scale from 1 = "All the tics are typical of TS" to 5 = "None of the tics are typical of TS". Median scores and Spearman correlation between primary and senior reviewers were calculated. RESULTS Six videos without tic-like behaviors were excluded. Most videos depicted coprophenomena (coprolalia: 53.2%; copropraxia: 20.2%), often with unusual characteristics. Frequently, videos demonstrated atypical phenomenology such as very strong influence by the environment (motor: 54.3%; phonic: 54.3%), aggression (19.1%), throwing objects (22.3%), self-injurious behaviors (27.7%), and long phrases (>3 words; 45.7%). Most videos portrayed atypical, nontic behaviors (median [IQR] Likert ratings: 5 [4-5]). Primary vs. senior rater scores demonstrated moderate agreement (r = 0.46; P < 0.001). CONCLUSIONS TS symptom portrayals on highly viewed TikTok videos are predominantly not representative or typical of TS.
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Affiliation(s)
- Alonso Zea Vera
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Neurology, Children's National Hospital, Washington, District of Columbia.
| | - Adrienne Bruce
- Department of Pediatrics, Prisma Health, Greenville, South Carolina; University of South Carolina School of Medicine Greenville, Greenville, South Carolina
| | - Jordan Garris
- Department of Neurology, University of Virginia Medical Center, Charlottesville, Virginia
| | - Laura Tochen
- Department of Neurology, Children's National Hospital, Washington, District of Columbia
| | - Poonam Bhatia
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona
| | - Rebecca K Lehman
- Prisma Health-Midlands, Columbia, South Carolina; Department of Neurology, University of South Carolina, Columbia, South Carolina
| | - Wendi Lopez
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Steve W Wu
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Donald L Gilbert
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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17
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Szejko N, Robinson S, Hartmann A, Ganos C, Debes NM, Skov L, Haas M, Rizzo R, Stern J, Münchau A, Czernecki V, Dietrich A, Murphy TL, Martino D, Tarnok Z, Hedderly T, Müller-Vahl KR, Cath DC. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part I: assessment. Eur Child Adolesc Psychiatry 2022; 31:383-402. [PMID: 34661764 PMCID: PMC8521086 DOI: 10.1007/s00787-021-01842-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/30/2021] [Indexed: 11/03/2022]
Abstract
In 2011 a working group of the European Society for the Study of Tourette Syndrome (ESSTS) has developed the first European assessment guidelines for Tourette syndrome (TS). Now, we present an updated version 2.0 of these European clinical guidelines for Tourette syndrome and other tic disorders, part I: assessment. Therefore, the available literature has been thoroughly screened, supplemented with national guidelines across countries and discussions among ESSTS experts. Diagnostic changes between DSM-IV and DSM-5 classifications were taken into account and new information has been added regarding differential diagnoses, with an emphasis on functional movement disorders in both children and adults. Further, recommendations regarding rating scales to evaluate tics, comorbidities, and neuropsychological status are provided. Finally, results from a recently performed survey among ESSTS members on assessment in TS are described. We acknowledge that the Yale Global Tic Severity Scale (YGTSS) is still the gold standard for assessing tics. Recommendations are provided for scales for the assessment of tics and psychiatric comorbidities in patients with TS not only in routine clinical practice, but also in the context of clinical research. Furthermore, assessments supporting the differential diagnosis process are given as well as tests to analyse cognitive abilities, emotional functions and motor skills.
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Affiliation(s)
- Natalia Szejko
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
- Department of Bioethics, Medical University of Warsaw, Warsaw, Poland
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, USA
| | - Sally Robinson
- Tic and Neurodevelopmental Movements Service (TANDeM), Children's Neurosciences Centre, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | | | - Christos Ganos
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Nanette M Debes
- Paediatric Department, Herlev University Hospital, Herlev, Denmark
| | - Liselotte Skov
- Paediatric Department, Herlev University Hospital, Herlev, Denmark
| | - Martina Haas
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Renata Rizzo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Jeremy Stern
- Department of Neurology, St George's Hospital, St George's University of London, London, UK
| | | | | | - Andrea Dietrich
- Department of Child and Adolescent Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tara L Murphy
- Tic Disorder Clinic, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Davide Martino
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | | | - Tammy Hedderly
- Tic and Neurodevelopmental Movements Service (TANDeM), Children's Neurosciences Centre, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Kirsten R Müller-Vahl
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Danielle C Cath
- Department of Psychiatry, University Medical Center Groningen, Rijks Universiteit Groningen, GGZ Drenthe Mental Health Institution, Hanzeplein 1, Assen, 9713, Groningen, The Netherlands.
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18
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Prato A, Saia F, Milana MC, Scerbo M, Barone R, Rizzo R. Functional tic-like behaviours during the COVID-19 pandemic: Follow-up over 12 months. Front Pediatr 2022; 10:1003825. [PMID: 36699317 PMCID: PMC9869029 DOI: 10.3389/fped.2022.1003825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Functional tics are included in the wide spectrum of functional movement disorders (FMDs). Their distinction from organic tics is challenging because they both phenomenologically present common features. During the COVID-19 pandemic, there has been an increase in functional tic-like behaviours in vulnerable children and adolescents after social media exposure. This study explores the phenomenology and course of a cohort of newly diagnosed functional tic-like behaviors. METHODS We analysed clinical data of 243 patients affected by tic disorders collected at outpatient Tourette Clinic, Child and Adolescent Neurology and Psychiatry Unit, Catania University. Among the clinical cohort with functional tic-like behaviors, we evaluated the clinical course of symptoms at follow-up visits after 6 and 12 months. RESULTS Among the cohort of 243 patients referred for evaluation at our centre, 11 were diagnosed with functional tic-like behaviours. The majority of participants with functional tic-like behaviours were female with a mean age of 15 years old and presented an explosive symptom's onset. At follow-up visit after 12 months, patients with functional tic-like behaviors showed a significant variation in the severity of tics and anxiety symptoms. Conversely, depressive, and obsessive-compulsive symptoms did not significantly differ during the follow-up. CONCLUSION Our data suggest that several characteristics in clinical course and their phenomenology can help clinicians to distinguish functional tic-like behaviours from organic tics. Our results also suggest a better outcome for tics and anxiety symptoms respect on other comorbidities. A prompt diagnosis and management not only of tics but also comorbidities are recommended, as generally conventional pharmacotherapy for tics does not have positive effects on these patients.
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Affiliation(s)
- Adriana Prato
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy.,Department of Cognitive Sciences, Psychology, Education and Cultural Studies, University of Messina, Messina, Italy
| | - Federica Saia
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Maria Chiara Milana
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Miriam Scerbo
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Rita Barone
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
| | - Renata Rizzo
- Child and Adolescent Neurology and Psychiatric Section, Department of Clinical and Experimental Medicine, Catania University, Catania, Italy
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19
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Martindale JM, Mink JW. The Rise of Functional Tic-Like Behaviors: What Do the COVID-19 Pandemic and Social Media Have to Do With It? A Narrative Review. Front Pediatr 2022; 10:863919. [PMID: 35899132 PMCID: PMC9309505 DOI: 10.3389/fped.2022.863919] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND There has been a rise in explosive onset of tic-like behaviors during the COVID-19 pandemic. Historically, this is an uncommon phenomenology of functional movement disorders across all ages. Both the psychological burden of the pandemic and social media usage have been implicated in the rise of these tic-like behaviors. METHODS This paper provides a narrative review of the literature on chronic tic disorders, functional tics, and mass functional illness with particular focus on the key distinguishing features, role of social media, and the role of COVID-19. RESULTS The COVID-19 pandemic has profoundly affected the mental health of many individuals, including children, adolescents, and their caregivers. Implementation of lockdowns, lifestyle disruptions, school closures, and social distancing have driven a surge in social media and digital technology use. The combination of predisposing factors, the psychological burden of the COVID-19 pandemic, and social media are implicated in the rise and spread of tic-like behaviors; which may represent a modern-day form of mass functional illness. While many of the features overlap with functional tics, there are emerging distinctive features that are important to recognize. A more encompassing term, Functional Tic-Like Behaviors, is used to better reflect multiple contributing factors. CONCLUSION Knowledge of these differences is essential to mitigate downstream health effects and poor outcomes.
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Affiliation(s)
- Jaclyn M Martindale
- Department of Neurology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States
| | - Jonathan W Mink
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
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20
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Cavanna A, Purpura G, Nacinovich R. Neurodevelopmental versus functional Tics: The state of the art. ARCHIVES OF MEDICINE AND HEALTH SCIENCES 2022. [DOI: 10.4103/amhs.amhs_246_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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21
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Paulus T, Schappert R, Bluschke A, Alvarez-Fischer D, Naumann KER, Roessner V, Bäumer T, Beste C, Münchau A. Questioning the definition of Tourette syndrome-evidence from machine learning. Brain Commun 2021; 3:fcab282. [PMID: 34993475 PMCID: PMC8728701 DOI: 10.1093/braincomms/fcab282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/24/2021] [Accepted: 10/04/2021] [Indexed: 11/13/2022] Open
Abstract
Tics in Tourette syndrome are often difficult to discern from single spontaneous movements or vocalizations in healthy people. In this study, videos of patients with Tourette syndrome and healthy controls were taken and independently scored according to the Modified Rush Videotape Rating Scale. We included n = 101 patients with Tourette syndrome (71 males, 30 females, mean age 17.36 years ± 10.46 standard deviation) and n = 109 healthy controls (57 males, 52 females, mean age 17.62 years ± 8.78 standard deviation) in a machine learning-based analysis. The results showed that the severity of motor tics, but not vocal phenomena, is the best predictor to separate and classify patients with Tourette syndrome and healthy controls. This finding questions the validity of current diagnostic criteria for Tourette syndrome requiring the presence of both motor and vocal tics. In addition, the negligible importance of vocalizations has implications for medical practice, because current recommendations for Tourette syndrome probably also apply to the large group with chronic motor tic disorders.
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Affiliation(s)
- Theresa Paulus
- Institute of Systems Motor Science, University of Lübeck, 23562 Lübeck, Germany
- Department of Neurology, University of Lübeck, 23538 Lübeck, Germany
| | - Ronja Schappert
- Institute of Systems Motor Science, University of Lübeck, 23562 Lübeck, Germany
| | - Annet Bluschke
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, 01069 Dresden, Germany
- Faculty of Medicine, University Neuropsychology Centre, TU Dresden, 01069 Dresden, Germany
| | | | - Kim Ezra Robin Naumann
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, 01069 Dresden, Germany
- Faculty of Medicine, University Neuropsychology Centre, TU Dresden, 01069 Dresden, Germany
| | - Veit Roessner
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, 01069 Dresden, Germany
| | - Tobias Bäumer
- Institute of Systems Motor Science, University of Lübeck, 23562 Lübeck, Germany
| | - Christian Beste
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, 01069 Dresden, Germany
- Faculty of Medicine, University Neuropsychology Centre, TU Dresden, 01069 Dresden, Germany
- Cognitive Psychology, Faculty of Psychology, Shandong Normal University, Qianfoshan Campus, No. 88 East Wenhua Road, Lixia District, Jinan, 250014, China
| | - Alexander Münchau
- Institute of Systems Motor Science, University of Lübeck, 23562 Lübeck, Germany
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22
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Clinical Practice Patterns in Tic Disorders Among Movement Disorder Society Members. Tremor Other Hyperkinet Mov (N Y) 2021; 11:43. [PMID: 34754602 PMCID: PMC8555622 DOI: 10.5334/tohm.656] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/24/2021] [Indexed: 12/26/2022] Open
Abstract
Background Tic disorders belong to the broad spectrum of pediatric and adult movement disorders. The wide variability in clinical presentations, applied assessment tools, and treatments are poorly understood. Objectives To map practices and knowledge base of movement disorder clinicians concerning clinical features, pathophysiology, and treatment approaches in tic disorders. Methods A 33-item survey was developed by the Tic Disorders and Tourette syndrome Study Group members of the Movement Disorder Society. The survey was distributed to the complete society membership and included responses from 346 members, 314 of whom reported treating tic disorders. Results Approximately one third of survey respondents (35%) frequently evaluated patients with tics. The data revealed widespread use of existing guidelines (about 70%) and screening for comorbid disorders (>90%). The most common investigations used to rule out secondary causes of tics were imaging (92%), laboratory tests (66%) and neurophysiology (38%). Functional tics were the second most common tic etiology following primary tics. Only 27% of respondents reported confidence in knowledge about tic pathogenesis. Top rated interventions to treat tics were psychoeducation, cognitive behavioral intervention for tics (CBIT) and treatment for neuropsychiatric comorbidities. Antipsychotics were ranked as the most effective pharmacologic tic intervention. Conclusions The majority of movement disorders specialists do not frequently encounter tics. There was sparse knowledge about tic pathophysiology. Psychoeducation, CBIT, the treatment of neuropsychiatric comorbidities and use of antipsychotics emerged as the most common interventions to treat tics. These results provide insight into what will be needed to improve the diagnosis and treatment of tic disorders.
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23
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Paulus T, Bäumer T, Verrel J, Weissbach A, Roessner V, Beste C, Münchau A. Pandemic Tic-like Behaviors Following Social Media Consumption. Mov Disord 2021; 36:2932-2935. [PMID: 34558735 DOI: 10.1002/mds.28800] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/23/2021] [Accepted: 09/02/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Currently, there is a marked increase of young people with sudden onset of tic-like behaviors (TLBs) resembling movements and vocalizations presented on social media videos as "Tourette's syndrome." OBJECTIVE To delineate clinical phenomenology of TLBs after social media exposure in comparison with clinical features of Tourette's syndrome. METHODS We compared demographic and clinical variables between 13 patients with TLBs and 13 age- and sex-related patients with Tourette's syndrome. RESULTS Patients with TLBs had several characteristics allowing to distinguish them from patients with Tourette's syndrome, some of which discriminated perfectly (ie, abrupt symptom onset, lack of spontaneous symptom fluctuations, symptom deterioration in the presence of others) and some nearly perfectly (ie, predominantly complex movements involving trunk/extremities). Also, symptom onset was significantly later. CONCLUSIONS TLBs after social media consumption differ from tics in Tourette's syndrome, strongly suggesting that these phenomena are categorically different conditions. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Theresa Paulus
- Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany.,Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Tobias Bäumer
- Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany
| | - Julius Verrel
- Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany
| | - Anne Weissbach
- Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany
| | - Veit Roessner
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Christian Beste
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, Dresden, Germany.,TU Dresden, University Neuropsychology Centre, Faculty of Medicine, Dresden, Germany.,Cognitive Psychology, Faculty of Psychology, Shandong Normal University, Jinan, China
| | - Alexander Münchau
- Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany
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24
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Müller-Vahl KR, Pisarenko A, Jakubovski E, Fremer C. Stop that! It's not Tourette's but a new type of mass sociogenic illness. Brain 2021; 145:476-480. [PMID: 34424292 PMCID: PMC9014744 DOI: 10.1093/brain/awab316] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/20/2021] [Accepted: 07/28/2021] [Indexed: 11/25/2022] Open
Abstract
We report the first outbreak of a new type of mass sociogenic illness that in contrast to all previously reported episodes is spread solely via social media. Accordingly, we suggest the more specific term ‘mass social media-induced illness’. In Germany, the current outbreak of mass social media-induced illness is initiated by a ‘virtual’ index case, who is the second most successful YouTube creator in Germany and enjoys enormous popularity among young people. Affected teenagers present with similar or identical functional ‘Tourette-like’ behaviours, which can be clearly differentiated from tics in Tourette syndrome. Functional ‘Tourette-like’ symptoms can be regarded as the ‘modern’ form of the well-known motor variant of mass sociogenic illness. Moreover, they can be viewed as the 21st century expression of a culture-bound stress reaction of our post-modern society emphasizing the uniqueness of individuals and valuing their alleged exceptionality, thus promoting attention-seeking behaviours and aggravating the permanent identity crisis of modern man. We wish to raise awareness of the current global Tourette-like mass social media-induced illness outbreak. A large number of young people across different countries are affected, with considerable impact on health care systems and society as a whole, since spread via social media is no longer restricted to specific locations such as local communities or school environments spread via social media is no longer restricted to specific locations such as schools or towns.
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Affiliation(s)
- Kirsten R Müller-Vahl
- Department of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Germany
| | - Anna Pisarenko
- Department of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Germany
| | - Ewgeni Jakubovski
- Department of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Germany
| | - Carolin Fremer
- Department of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Germany
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25
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Pringsheim T, Ganos C, McGuire JF, Hedderly T, Woods D, Gilbert DL, Piacentini J, Dale RC, Martino D. Rapid Onset Functional Tic-Like Behaviors in Young Females During the COVID-19 Pandemic. Mov Disord 2021; 36:2707-2713. [PMID: 34387394 PMCID: PMC8441698 DOI: 10.1002/mds.28778] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Tamara Pringsheim
- Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Christos Ganos
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Joseph F McGuire
- Department of Psychiatry and Behavioural Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tammy Hedderly
- Guy's and St Thomas' NHS Foundation Trust, Evelina London Children's Hospital UK, London, United Kingdom
| | - Douglas Woods
- Department of Psychology, Marquette University, Milwaukee, Wisconsin, USA
| | - Donald L Gilbert
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - John Piacentini
- Department of Psychiatry and Biobehavioural Sciences, University of California Los Angeles, Los Angeles, California, USA
| | - Russell C Dale
- Kids Neuroscience Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Davide Martino
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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26
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Pringsheim T, Martino D. Rapid onset of functional tic-like behaviours in young adults during the COVID-19 pandemic. Eur J Neurol 2021; 28:3805-3808. [PMID: 34293224 PMCID: PMC8444872 DOI: 10.1111/ene.15034] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
Background and purpose Clinicians have reported an increase in functional tic‐like behaviours in children and youth during the COVID‐19 pandemic. We describe adults developing rapid onset of functional tic‐like behaviours between May 2020 and June 2021. Methods Data were analysed from the Adult Tic Disorders Registry, a single‐site,12‐month prospective cohort study that began enrolment in January 2021. We compared clinical features of participants with Tourette syndrome or persistent motor/vocal tic disorder to participants with rapid onset tic‐like behaviours. Results Thirty‐three participants registered between January and June of 2021; nine had rapid onset tic‐like behaviours, and 24 had Tourette syndrome or persistent motor tic disorder. Participants with rapid onset tic‐like behaviours were younger (19.9 vs. 38.6 years, p = 0.003), had older age at onset (15.3 vs. 10.1, p = 0.0009), and were more likely female (p < 0.0001). They had higher motor and vocal tic severity and impairment scores (all p < 0.01) and were more likely to have complex arm/hand motor tics (p < 0.0001), complex vocal tics (p < 0.0001), and coprolalia (p = 0.004). They had significantly higher scores on all mental health symptom self‐report measures (all p < 0.05) and were significantly more likely to be diagnosed with depression (p = 0.03). Conclusions The clinical features that help differentiate rapid onset tic‐like behaviours from Tourette syndrome or persistent motor tic disorder include their phenomenology, onset age, and clinical course. Rapid onset tic‐like behaviours are a distinct subtype of functional neurological disorder that has emerged during the COVID‐19 pandemic in young people and appears to be strongly socially influenced.
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Affiliation(s)
- Tamara Pringsheim
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Davide Martino
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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27
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Swearing and coprophenomena - A multidimensional approach. Neurosci Biobehav Rev 2021; 126:12-22. [PMID: 33757814 DOI: 10.1016/j.neubiorev.2021.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
Swearing, cursing, expletives - all these terms are used to describe the utterance of taboo words. Studies show that swearing makes up around 0.5 % of the daily spoken content, however, the inter-individual variability is very high. One kind of pathologic swearing is coprolalia in Tourette syndrome (TS), which describes the involuntary outburst of taboo words. Coprolalia occurs in approximately 20-30 % of all patients with TS. This review compares swearing in healthy people and coprolalia in people with TS and is the first one to develop a multidimensional framework to account for both phenomena from a similar perspective. Different research findings are embedded in one theoretical framework consisting of reasons, targets, functions/effects and influencing factors for swearing and coprolalia. Furthermore, the very limited research investigating obscene gestures and copropraxia, compulsive obscene gestures, is summarized. New research questions and gaps are brought up for swearing, obscene gestures and coprophenomena.
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28
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Functional movement disorders. Rev Neurol (Paris) 2020; 176:244-251. [DOI: 10.1016/j.neurol.2019.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/30/2019] [Accepted: 08/27/2019] [Indexed: 11/23/2022]
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29
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Mainka T, Balint B, Gövert F, Kurvits L, van Riesen C, Kühn AA, Tijssen MAJ, Lees AJ, Müller-Vahl K, Bhatia KP, Ganos C. The spectrum of involuntary vocalizations in humans: A video atlas. Mov Disord 2019; 34:1774-1791. [PMID: 31651053 DOI: 10.1002/mds.27855] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/22/2019] [Accepted: 08/21/2019] [Indexed: 12/11/2022] Open
Abstract
In clinical practice, involuntary vocalizing behaviors are typically associated with Tourette syndrome and other tic disorders. However, they may also be encountered throughout the entire tenor of neuropsychiatry, movement disorders, and neurodevelopmental syndromes. Importantly, involuntary vocalizing behaviors may often constitute a predominant clinical sign, and, therefore, their early recognition and appropriate classification are necessary to guide diagnosis and treatment. Clinical literature and video-documented cases on the topic are surprisingly scarce. Here, we pooled data from 5 expert centers of movement disorders, with instructive video material to cover the entire range of involuntary vocalizations in humans. Medical literature was also reviewed to document the range of possible etiologies associated with the different types of vocalizing behaviors and to explore treatment options. We propose a phenomenological classification of involuntary vocalizations within different categorical domains, including (1) tics and tic-like vocalizations, (2) vocalizations as part of stereotypies, (3) vocalizations as part of dystonia or chorea, (4) continuous vocalizing behaviors such as groaning or grunting, (5) pathological laughter and crying, (6) vocalizations resembling physiological reflexes, and (7) other vocalizations, for example, those associated with exaggerated startle responses, as part of epilepsy and sleep-related phenomena. We provide comprehensive lists of their associated etiologies, including neurodevelopmental, neurodegenerative, neuroimmunological, and structural causes and clinical clues. We then expand on the pathophysiology of the different vocalizing behaviors and comment on available treatment options. Finally, we present an algorithmic approach that covers the wide range of involuntary vocalizations in humans, with the ultimate goal of improving diagnostic accuracy and guiding appropriate treatment. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Tina Mainka
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Bettina Balint
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK.,Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Felix Gövert
- Department of Neurology, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Lille Kurvits
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Christoph van Riesen
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany.,Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Andrea A Kühn
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Marina A J Tijssen
- Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Andrew J Lees
- Reta Lila Weston Institute of Neurological Studies, UCL, Institute of Neurology, London, UK
| | - Kirsten Müller-Vahl
- Clinic of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK
| | - Christos Ganos
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
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30
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Ganos C, Martino D, Espay AJ, Lang AE, Bhatia KP, Edwards MJ. Tics and functional tic-like movements: Can we tell them apart? Neurology 2019; 93:750-758. [PMID: 31551261 DOI: 10.1212/wnl.0000000000008372] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/31/2019] [Indexed: 11/15/2022] Open
Abstract
Within the broad spectrum of movement disorders, tics and functional tic-like movements belong to a particular clinical category. Both types of movements are within the range of normal movement kinematics and muscle synergies, but appear repetitive and without appropriate context embedment. Historically, there have been many attempts to separate the 2 types of movements, but because of their phenomenological overlap, clinical distinction may be prone to error, and misdiagnoses may often occur. Most importantly, the 2 types of movement may coexist. Here, we review the available literature on the 2 types of motor phenomena and demonstrate some of the difficulties in distinguishing tics from functional tic-like movements on clinical grounds. We also highlight similarities and differences in pathophysiologic characteristics, documenting the significance of action monitoring, attentional allocation, and behavioral reinforcement in both types of movements, as well as in their risk factors. We discuss the overlap of current behavioral treatments for tics and functional tic-like movements and emphasize implications of diagnostic mislabeling. Such implications include the need to tailor behavioral treatment approaches to individual phenomenological profiles and guiding decision making for severe patients requiring invasive interventions, such as deep brain stimulation. A deeper insight from clinicians with respect to persisting challenges in classifying and differentiating these motor phenomena could accelerate the development of reliable clinical and physiologic markers (i.e., next generation phenotyping) and a neurobiology-driven therapeutic approach for these motor phenomena.
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Affiliation(s)
- Christos Ganos
- From the Department of Neurology (C.G.), Charité University Medicine Berlin, Germany; Department of Clinical Neurosciences (D.M.), Cumming School of Medicine, University of Calgary and Hotchkiss Brain Institute, AB, Canada; Department of Neurology (A.J.E.), James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, OH; Division of Neurology (A.E.L.), Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital-UHN, University of Toronto, ON, Canada; Department of Clinical and Movement Neurosciences (K.P.B.), Queen Square Institute of Neurology, University College London; and Neurosciences Research Centre (M.E.), Molecular and Clinical Sciences Institute, St George's University of London.
| | - Davide Martino
- From the Department of Neurology (C.G.), Charité University Medicine Berlin, Germany; Department of Clinical Neurosciences (D.M.), Cumming School of Medicine, University of Calgary and Hotchkiss Brain Institute, AB, Canada; Department of Neurology (A.J.E.), James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, OH; Division of Neurology (A.E.L.), Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital-UHN, University of Toronto, ON, Canada; Department of Clinical and Movement Neurosciences (K.P.B.), Queen Square Institute of Neurology, University College London; and Neurosciences Research Centre (M.E.), Molecular and Clinical Sciences Institute, St George's University of London
| | - Alberto J Espay
- From the Department of Neurology (C.G.), Charité University Medicine Berlin, Germany; Department of Clinical Neurosciences (D.M.), Cumming School of Medicine, University of Calgary and Hotchkiss Brain Institute, AB, Canada; Department of Neurology (A.J.E.), James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, OH; Division of Neurology (A.E.L.), Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital-UHN, University of Toronto, ON, Canada; Department of Clinical and Movement Neurosciences (K.P.B.), Queen Square Institute of Neurology, University College London; and Neurosciences Research Centre (M.E.), Molecular and Clinical Sciences Institute, St George's University of London
| | - Anthony E Lang
- From the Department of Neurology (C.G.), Charité University Medicine Berlin, Germany; Department of Clinical Neurosciences (D.M.), Cumming School of Medicine, University of Calgary and Hotchkiss Brain Institute, AB, Canada; Department of Neurology (A.J.E.), James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, OH; Division of Neurology (A.E.L.), Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital-UHN, University of Toronto, ON, Canada; Department of Clinical and Movement Neurosciences (K.P.B.), Queen Square Institute of Neurology, University College London; and Neurosciences Research Centre (M.E.), Molecular and Clinical Sciences Institute, St George's University of London
| | - Kailash P Bhatia
- From the Department of Neurology (C.G.), Charité University Medicine Berlin, Germany; Department of Clinical Neurosciences (D.M.), Cumming School of Medicine, University of Calgary and Hotchkiss Brain Institute, AB, Canada; Department of Neurology (A.J.E.), James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, OH; Division of Neurology (A.E.L.), Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital-UHN, University of Toronto, ON, Canada; Department of Clinical and Movement Neurosciences (K.P.B.), Queen Square Institute of Neurology, University College London; and Neurosciences Research Centre (M.E.), Molecular and Clinical Sciences Institute, St George's University of London
| | - Mark J Edwards
- From the Department of Neurology (C.G.), Charité University Medicine Berlin, Germany; Department of Clinical Neurosciences (D.M.), Cumming School of Medicine, University of Calgary and Hotchkiss Brain Institute, AB, Canada; Department of Neurology (A.J.E.), James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, OH; Division of Neurology (A.E.L.), Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital-UHN, University of Toronto, ON, Canada; Department of Clinical and Movement Neurosciences (K.P.B.), Queen Square Institute of Neurology, University College London; and Neurosciences Research Centre (M.E.), Molecular and Clinical Sciences Institute, St George's University of London
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Cannabinoids in functional tic-like movements. Parkinsonism Relat Disord 2019; 60:179-181. [DOI: 10.1016/j.parkreldis.2018.09.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/21/2018] [Accepted: 09/24/2018] [Indexed: 11/23/2022]
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Hartmann A, Worbe Y. Tourette syndrome: clinical spectrum, mechanisms and personalized treatments. Curr Opin Neurol 2018; 31:504-509. [DOI: 10.1097/wco.0000000000000575] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Gilles de la Tourette syndrome is a chronic and complex tic disorder accompanied by specific behavioral problems in the majority of patients. With its multifaceted interplay between motion and emotion, this condition is a paradigmatic example of the science and art of clinical neuropsychiatry. This review article encompasses the clinical phenomenology of motor and vocal tics and associated sensory experiences (premonitory urges), as well as the behavioral spectrum of the most common comorbidities, including obsessive-compulsive disorder, attention-deficit and hyperactivity disorder, affective symptoms, and impulsivity. Knowledge of the contributions of both tics and behavioral problems to patients' health-related quality of life across the lifespan should assist treating clinicians in formulating a targeted management plan. Although the exact pathophysiology of Gilles de la Tourette syndrome remains elusive, research into therapeutic interventions has expanded the range of available interventions across multiple domains. A thorough understanding of the neurology and psychiatry of this condition is of key importance to meet the needs of this patient population, from the formulation of an accurate diagnosis to the implementation of effective treatment strategies.
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Afshangian F, Nami M, Abolhasani Foroughi A, Rahimi A, Husak R, Fabbro F, Tomasino B, Kremer C. Coprolalia in aphasic patients with stroke: a longitudinal observation from the BLAS 2T database. Neurocase 2017; 23:249-262. [PMID: 29027506 DOI: 10.1080/13554794.2017.1387274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The BLAS2T (bilingual aphasia in stroke-study team) initiative has been a multi-center attempt to investigate longitudinal changes in language function in a cohort of stroke subjects. This report discusses linguistic performance in four cases from the BLAS2T database who demonstrated coprolalia as an irresistible urge to say obscene words. Coprolalia was found to partly resolve in a 30-day follow-up in three cases. Recognition of coprolalia and language recovery patterns in bilingual aphasic patients with stroke would potentially lead to their even better individualized care and neurolinguistic/cognitive rehabilitation.
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Affiliation(s)
- Fazlallah Afshangian
- a Department of English Language, Faculty of Foreign Languages , Rodaki Institute of Higher Education , Tonekabon , Iran
| | - Mohammad Nami
- b Department of Neuroscience , School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences , Shiraz , Iran.,c Neuroscience Laboratory (Brain, Cognition and Behavior), Department of Neuroscience , School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences , Shiraz , Iran.,d Clinical Neurology Research Center , Shiraz University of Medical Sciences , Shiraz , Iran
| | - Amin Abolhasani Foroughi
- e Department of Radiology, School of Medicine , Shiraz University of Medical Sciences , Shiraz , Iran.,f Medical Imaging Research Center , Shiraz University of Medical Sciences , Shiraz , Iran
| | - Amir Rahimi
- g Department of Molecular Medicine , School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences , Shiraz , Iran.,h Bioinformatics and Computational Biology Research Center , Shiraz University of Medical Sciences , Shiraz , Iran
| | - Ryan Husak
- i SLP at Baptist Health Lexington , University of Kentucky , Lexington , KY , USA
| | - Franco Fabbro
- j Neurolinguistic Unit , Scientific Institute "E.Medea" , Udine , Italy
| | - Barbara Tomasino
- j Neurolinguistic Unit , Scientific Institute "E.Medea" , Udine , Italy
| | - Christine Kremer
- k Neurology Department, Skåne University Hospital , Department of Clinical Sciences, Lund University , Lund , Sweden
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