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Friedrich J, Rawish T, Bluschke A, Frings C, Beste C, Münchau A. Cognitive and Neural Mechanisms of Behavior Therapy for Tics: A Perception-Action Integration Approach. Biomedicines 2023; 11:1550. [PMID: 37371645 DOI: 10.3390/biomedicines11061550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
European clinical guidelines recommend the use of Exposure and Response Prevention (ERP) and Comprehensive Behavioral Intervention for Tics (CBIT) as first-line treatments for tic disorders. Although ongoing efforts in research are being made to understand the mechanisms underlying these behavioral approaches, as of yet, the neurophysiological mechanisms behind behavioral interventions are poorly understood. However, this is essential to tailor interventions to individual patients in order to increase compliance and efficacy. The Theory of Event Coding (TEC) and its derivative BRAC (Binding and Retrieval in Action Control) provide a theoretical framework to investigate cognitive and neural processes in the context of tic disorders. In this context, tics are conceptualized as a phenomenon of enhanced perception-action binding, with premonitory urges constituting the perceptual and the motor or vocal expression constituting the action part of an event file. Based on this, CBIT is assumed to strongly affect stimulus-response binding in the context of response selection, whereas the effects of ERP presumably unfold during stimulus-response binding in the response inhibition context. Further studies are needed to clarify the neurophysiological processes underlying behavioral interventions to enable the individualization and further development of therapeutic approaches for tic disorders.
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Affiliation(s)
- Julia Friedrich
- Institute of Systems Motor Science, Center for Brain, Behavior and Metabolism (CBBM), University of Lübeck, 23562 Lübeck, Germany
| | - Tina Rawish
- Institute of Systems Motor Science, Center for Brain, Behavior and Metabolism (CBBM), University of Lübeck, 23562 Lübeck, Germany
| | - Annet Bluschke
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, 01307 Dresden, Germany
| | - Christian Frings
- Department of Cognitive Psychology, Faculty of Psychology, University of Trier, 54296 Trier, Germany
| | - Christian Beste
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, 01307 Dresden, Germany
- University Neuropsychology Centre, Faculty of Medicine, Technische Universität Dresden, 01307 Dresden, Germany
- Cognitive Psychology, Faculty of Psychology, Shandong Normal University, Jinan 250014, China
| | - Alexander Münchau
- Institute of Systems Motor Science, Center for Brain, Behavior and Metabolism (CBBM), University of Lübeck, 23562 Lübeck, Germany
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Woods DW, Himle MB, Stiede JT, Pitts BX. Behavioral Interventions for Children and Adults with Tic Disorder. Annu Rev Clin Psychol 2023; 19:233-260. [PMID: 37159286 DOI: 10.1146/annurev-clinpsy-080921-074307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Over the past decade, behavioral interventions have become increasingly recognized and recommended as effective first-line therapies for treating individuals with tic disorders. In this article, we describe a basic theoretical and conceptual framework through which the reader can understand the application of these interventions for treating tics. The three primary behavioral interventions for tics with the strongest empirical support (habit reversal, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention) are described. Research on the efficacy and effectiveness of these treatments is summarized along with a discussion of the research evaluating the delivery of these treatments in different formats and modalities. The article closes with a review of the possible mechanisms of change underlying behavioral interventions for tics and areas for future research.
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Affiliation(s)
- Douglas W Woods
- Department of Psychology, Marquette University, Milwaukee, Wisconsin, USA;
| | - Michael B Himle
- Department of Psychology, University of Utah, Salt Lake City, Utah, USA
| | - Jordan T Stiede
- Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Brandon X Pitts
- Department of Psychology, Marquette University, Milwaukee, Wisconsin, USA;
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Chou CY, Agin-Liebes J, Kuo SH. Emerging therapies and recent advances for Tourette syndrome. Heliyon 2023; 9:e12874. [PMID: 36691528 PMCID: PMC9860289 DOI: 10.1016/j.heliyon.2023.e12874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/27/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
Tourette syndrome is the most prevalent hyperkinetic movement disorder in children and can be highly disabling. While the pathomechanism of Tourette syndrome remains largely obscure, recent studies have greatly improved our knowledge about this disease, providing a new perspective in our understanding of this condition. Advances in electrophysiology and neuroimaging have elucidated that there is a reduction in frontal cortical volume and reduction of long rage connectivity to the frontal lobe from other parts of the brain. Several genes have also been identified to be associated with Tourette syndrome. Treatment of Tourette syndrome requires a multidisciplinary approach which includes behavioral and pharmacological therapy. In severe cases surgical therapy with deep brain stimulation may be warranted, though the optimal location for stimulation is still being investigated. Studies on alternative therapies including traditional Chinese medicine and neuromodulation, such as transcranial magnetic stimulation have shown promising results, but still are being used in an experimental basis. Several new therapies have also recently been tested in clinical trials. This review provides an overview of the latest findings with regards to genetics and neuroimaging for Tourette syndrome as well as an update on advanced therapeutics.
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Affiliation(s)
- Chih-Yi Chou
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Initiative for Columbia Ataxia and Tremor, Columbia University, New York, NY, USA
| | - Julian Agin-Liebes
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Initiative for Columbia Ataxia and Tremor, Columbia University, New York, NY, USA
| | - Sheng-Han Kuo
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Initiative for Columbia Ataxia and Tremor, Columbia University, New York, NY, USA
- Corresponding author. 650 West 168th Street, Room 305, New York, NY, 10032, USA. Fax: +(212) 305 1304.
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Abstract
Purpose of Review This study aims to examine the treatments currently available for Tourette syndrome (TS) and to discuss evolving therapies, spanning behavioral, pharmacologic, complementary and alternative medicine, and neuromodulation approaches. Recent Findings Behavioral therapies have undergone several modifications to improve accessibility, including transitioning to a virtual format which is particularly important in the current pandemic. There are several recent or ongoing pharmacologic studies that have shown promise including the selective D1 receptor antagonist ecopipam and various cannabinoid compounds. Adaptive DBS may enable the physiologic markers of tics to determine stimulation parameters and improve tic outcomes related to neuromodulation. Summary In recent years, there has been a wealth of research across multiple treatment domains in the TS field. This review highlights exciting and new potential options for the future treatment of patients with TS.
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Affiliation(s)
- Jessica Frey
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Irene A Malaty
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
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Cen SS, Yu J, Wang Q, Deeb W, Wang KL, Shukla AW, Malaty I, Ramirez-Zamora A, Zhang JG, Hu W, Meng FG. Multidisciplinary Telemedicine Care for Tourette Syndrome: Minireview. Front Neurol 2021; 11:573576. [PMID: 33391146 PMCID: PMC7775481 DOI: 10.3389/fneur.2020.573576] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/16/2020] [Indexed: 11/24/2022] Open
Abstract
Tourette syndrome (TS) is a childhood-onset, chronic neuropsychiatric disorder characterized by multiple motor and vocal tics. TS poses a considerable burden on both patients and health care providers, leading to a major detriment of educational success, occupation, and interpersonal relationships. A multidisciplinary, specialist-driven management approach is required due to the complexity of TS. However, access to such specialty care is often dramatically limited by the patients' locations and the specialists' geographic clustering in large urban centers. Telemedicine uses electronic information and communication technology to provide and support health care when distance separates participants. Therefore, we conducted this mini-review to describe the latest information on telemedicine in the assessment and management of TS and discuss the potential contributions to care for TS patients with a multidisciplinary approach. We believe that telemedicine could be a revolutionary method in improving medical access to patients with TS.
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Affiliation(s)
- Shan-Shan Cen
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States.,Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Jun Yu
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Qiao Wang
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wissam Deeb
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States.,Department of Neurology, University of Massachusetts, Worcester, MA, United States
| | - Kai-Liang Wang
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aparna Wagle Shukla
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Irene Malaty
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Adolfo Ramirez-Zamora
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Jian-Guo Zhang
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Hu
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Fan-Gang Meng
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Chinese Institute for Brain Research, Beijing, China
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Yu L, Li Y, Zhang J, Yan C, Wen F, Yan J, Wang F, Liu J, Cui Y. The therapeutic effect of habit reversal training for Tourette syndrome: a meta-analysis of randomized control trials. Expert Rev Neurother 2020; 20:1189-1196. [PMID: 32948114 DOI: 10.1080/14737175.2020.1826933] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Comprehensive behavioral intervention for tics (CBIT) and habit reversal training (HRT) are forms of cognitive behavioral therapy that can effectively reduce tic symptoms in patients with tic disorders, but their efficacies and potential moderators were needed to be clarified. METHODS In the present study, a meta-analysis was performed to identify the efficacy of HRT and CBIT for individuals with tic disorders. The standard mean difference (SMD) was calculated to assess the effect size of the efficacy of HRT. Subgroup analysis and meta-regression analysis were performed to identify the potential heterogeneity of the SMD of HRT. RESULTS A total of 10 randomized controlled trials (RCTs) including 586 patients with tic disorders were identified. The pooled SMD was -0.43 (95% CI: -0.71, -0.16). The effect size of HRT was moderated by different 'Comparison Conditions' (it means the different behavioral therapies in the control group). CONCLUSION Overall, the authors found a small to medium effect size for the efficacy of HRT. As the most promising behavioral therapy, they conclude that HRT is effective for the treatment of patients with tic disorders. Further high-quality RCTs are needed to determine the efficacy of HRT compared with that of medications.
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Affiliation(s)
- Liping Yu
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Center for Children Healthy , Beijing, China
| | - Ying Li
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Center for Children Healthy , Beijing, China
| | - Jishui Zhang
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Center for Children Healthy , Beijing, China
| | - Chunmei Yan
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Center for Children Healthy , Beijing, China
| | - Fang Wen
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Center for Children Healthy , Beijing, China
| | - Junjuan Yan
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Center for Children Healthy , Beijing, China
| | - Fang Wang
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Center for Children Healthy , Beijing, China
| | - Jingran Liu
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Center for Children Healthy , Beijing, China
| | - Yonghua Cui
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Center for Children Healthy , Beijing, China
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Patel H, Nguyen K, Lehman E, Mainali G, Duda L, Byler D, Kumar A. Response to Correspondence "Complementary and Alternative…but Please Not Secret". J Child Neurol 2020; 35:861. [PMID: 32546043 DOI: 10.1177/0883073820932068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - KieuHanh Nguyen
- 12311Penn State College of Medicine, Hershey Medical Center, Hershey, PA, USA
| | - Erik Lehman
- Department of Public Health Sciences, 12311Penn State College of Medicine, Hershey, PA, USA
| | - Gayatra Mainali
- Department of Pediatrics, Division of Neurology, 12311Penn State College of Medicine/Penn State Children's Hospital, Hershey, PA, USA
| | - Laura Duda
- Department of Pediatrics, Division of Academic General Pediatrics, 12311Penn State College of Medicine/Penn State Children's Hospital, Hershey, PA, USA
| | | | - Ashutosh Kumar
- Department of Pediatrics, Division of Neurology, 12311Penn State College of Medicine/Penn State Children's Hospital, Hershey, PA, USA
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Abstract
INTRODUCTION Tourette syndrome is a neuropsychiatric condition defined by motor and phonic tics with onset in childhood. Many families have concerns regarding potential side effects of pharmacologic treatments, and often have difficulty accessing comprehensive behavioral intervention for tics. Patients and caregivers may turn to complementary and alternative medicine (CAM) as they perceive these as "natural" and therefore "safe." Although there are anecdotal reports of an increased use of CAM in Tourette syndrome patients, the exact prevalence is unknown. OBJECTIVE The purpose of this study was to identify commonly used CAM therapies for children with Tourette syndrome at Penn State Hershey Medical Center. METHODS A questionnaire was administered to the caregivers of children (<18 years old) via telephone. The data pertaining to demographics, type of CAM use, duration of use, adverse effects, and caregiver's perception of the effectiveness were collected. RESULTS A total of 110 patients participated in this survey. When inquired about the different CAM methods, 69.1% of the participants reported using 1 or more CAM therapies, and 58% of those who used CAM informed the doctor about their use. Ninety-three percent of those who used CAM therapy reported a decrease in tic frequency. The most commonly used CAM therapies were stress management (44.6%), herbal medicine (18.2%), homeopathy (12.7%), and meditation (9.1%). In total, 46% of the participants said that CAM helped more than medication. CONCLUSION The majority of patients interviewed were using CAM therapies, and a significant portion reported benefit greater than medication. More than half of all participants discussed CAM therapies with their physicians, and 63% of participants felt that their physicians would support their use of CAM therapies.
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Affiliation(s)
- Himadri Patel
- Penn State College of Medicine, Hershey Medical Center, Hershey, PA, USA
| | - KieuHanh Nguyen
- Penn State College of Medicine, Hershey Medical Center, Hershey, PA, USA
| | - Erik Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Gayatra Mainali
- Department of Pediatrics, Division of Neurology, Penn State College of Medicine/Penn State Children's Hospital, Hershey, PA, USA
| | - Laura Duda
- Department of Pediatrics, Division of Academic General Pediatrics, Penn State College of Medicine/Penn State Children's Hospital, Hershey, PA, USA
| | - Debra Byler
- Department of Pediatrics, Division of Neurology, Penn State College of Medicine/Penn State Children's Hospital, Hershey, PA, USA
| | - Ashutosh Kumar
- Department of Pediatrics, Division of Neurology, Penn State College of Medicine/Penn State Children's Hospital, Hershey, PA, USA
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Abstract
It is not clear whether the development of tics can be prevented. Contextual variables can impact tic expression; therefore, shifting attention to behaviors that reduce tics is an important part of decreasing tic severity. Several medications are effective in reducing tic severity, but side effects restrict their use. Behavioral treatment is the gold standard psychotherapy intervention for tic disorders, with Comprehensive Behavioral Intervention for Tics being the most well-supported nonpharmacological treatment. Although children may be unable to prevent the development of tics, they can still use several strategies to reduce tic severity and impairment.
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Affiliation(s)
- Jordan T Stiede
- Psychology Department, Marquette University, Cramer Hall, 307, PO Box 1881, Milwaukee, WI 53201-1881, USA
| | - Douglas W Woods
- Marquette University, Holthusen Hall, 305, PO Box 1881, Milwaukee, WI 5320-1881, USA.
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Singer HS, McDermott S, Ferenc L, Specht M, Mahone EM. Efficacy of Parent-Delivered, Home-Based Therapy for Tics. Pediatr Neurol 2020; 106:17-23. [PMID: 32165032 DOI: 10.1016/j.pediatrneurol.2019.12.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/23/2019] [Accepted: 12/27/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although behavioral therapy is an effective approach to reduce tics in children and adults, there is an insufficient availability and accessibility of behavioral therapy in the community. OBJECTIVE The goal of the study was to test the clinical efficacy of home-based, parent-provided behavioral therapy in children with Tourette syndrome aged seven to 13 years. METHOD An instructional habit reversal training-based video and guide was developed for use by parents. Eligible families, in this 10-week study, were enrolled in either a home-based therapy (DVD) group (received disk and written instructions) or an in-person therapist group (had scheduled visits with the therapist). Outcome scales included the Yale Global Tic Severity Scale, both the total Tic Severity Score and total Global Severity Score, and the parent report of Clinical Global Impressions of Improvement. RESULTS Forty-four children (mean age = 10.21 ± 1.69 years) were enrolled into either the DVD (n = 33) or in-person therapist (n = 11) groups. Eighteen completed the study-eight in the DVD and 10 in the in-person therapist group. Outcome measures showed significant reductions in Yale Global Tic Severity Scale change ratios: mean improvement on the Tic Severity Score was DVD 32.4% (P < 0.001) and in-person therapist 26.6% (P = 0.01); and for the Global Severity Score, DVD 33.7% (P < 0.001) and in-person therapist 26.7% (P < 0.001). CONCLUSIONS Home-based, parent-administered habit reversal training behavioral therapy is efficacious for reducing tics in children. Telephone contacts early in the DVD treatment course might reduce the number of dropouts.
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Affiliation(s)
- Harvey S Singer
- Johns Hopkins University School of Medicine, Baltimore, Maryland; Kennedy Krieger Institute, Baltimore, Maryland.
| | | | - Lisa Ferenc
- Kennedy Krieger Institute, Baltimore, Maryland
| | | | - E Mark Mahone
- Johns Hopkins University School of Medicine, Baltimore, Maryland; Kennedy Krieger Institute, Baltimore, Maryland
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