Premonitory Urge in Patients with Tics and Functional Tic-like Behaviors

BACKGROUND

Premonitory urges (PU) are well described in primary tics, but their frequency and intensity in functional tic-like behaviors (FTLB) are unclear.

OBJECTIVE

To study the experience of PU in patients with FTLB.

METHODS

We compared the results of the premonitory urge for tics scale (PUTS) in adults with tics and FTLB in the University of Calgary Adult Tic Registry.

RESULTS

We included 83 patients with tics and 40 with FTLB. When comparing patients with tics, FTLB with tics and FTLB only, we did not detect significant differences either in the total PUTS score (P = 0.39), or in any of the individual PUTS item sub-scores (P values ranging between 0.11 and 0.99).

CONCLUSIONS

Patients with FTLB report PU at similar frequency and intensity to patients with tics. This finding confirms that PU are not a useful feature to discriminate FTLB from tics.

Co-Occurring Anxiety in Youth with Tic Disorders: A Review

Objective: To review the current state of the literature regarding anxiety symptoms and anxiety disorders in chronic tic disorder (CTD). Results: We conducted a literature search on anxiety and tic disorders. Anxiety symptoms and anxiety disorders are common in youth with CTD, with ∼30%-50% of youth with CTD having at least one co-occurring anxiety disorder. Tics often improve by young adulthood but anxiety symptoms tend to persist, or worsen, over time. Anxiety and tics are closely related, but the exact nature of their relationship is poorly understood. We discuss some potential ways in which anxiety and tics are linked with an emphasis on the underlying brain circuitry involved. The relationship between anxiety and tics may be related to the premonitory urge. In addition, stress hormones may link anxiety and tics. Individuals with CTD have greater activation of their hypothalamic-pituitary-adrenal system in response to acute stress. We also review the impact of anxiety on youth with CTD and approaches to management of anxiety in youth. Conclusions: Anxiety is common in youth with CTD, is associated with more severe CTD, and can adversely affect a child's function. Thus, it is important to identify anxiety disorders in CTD and manage them appropriately.

Integrated cognitive behavioral intervention for functional tics (I-CBiT): case reports and treatment formulation

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.

Working Mechanisms of Exposure and Response Prevention in the Treatment of Tourette Syndrome and Tic Disorders Revisited: No Evidence for within-Session Habituation to Premonitory Urges

BACKGROUND

Exposure and response prevention (ERP) has been shown to be an effective treatment for Tourette syndrome (TS) and chronic tic disorders (CTD). ERP is based on voluntary tic suppression in combination with prolonged exposure to premonitory urges preceding tics. A prevailing hypothesis of the working mechanism underlying ERP in tics is habituation to the premonitory urges as a result of prolonged exposure. However, results so far are equivocal. This study aims to further explore the relation between urges and ERP in tics, by investigating the course of premonitory urges during ERP sessions.

METHODS

Using a data-driven approach, within-session habituation to premonitory urge intensity was investigated. In total, 29 TS patients rated urge intensity at seven timepoints during ten 1 h ERP sessions.

RESULTS/CONCLUSIONS

Latent growth modeling showed an increase in urge intensity during the first 15 min of each session followed by a plateau in the remaining 45 min of the session. This does not support the idea of within-session habituation to premonitory urges as a working mechanism of ERP. Other potential underlying working mechanisms are discussed and should be tested in future research.

The Severity and Neural Correlates of Premonitory Urge in Tourette Syndrome: A Systematic Review and Meta-Analysis

INTRODUCTION

Premonitory urge (PU) is an aversive bodily sensation that signals the onset of tic disorder.To our knowledge, PU typically precedes the appearance of tic symptoms, and both age and tic severity are correlated with PU. However, inconsistent findings have also been reported. Hence, we conducted a meta-analysis to examine the relationship among premonitory symptoms, patient age and the severity of tic symptoms, as well as to summarize the research on the neural underpinnings of PU in Tourette syndrome (TS).

METHODS

We conducted a literature search of relevant studies published between December 2005 and April 2022 using databases such as PubMed, Elsevier, PsycINFO, and Web of Science. Our analysis was carried out using R software with the assistance of the "meta" and "metafor" packages.

RESULTS

Our meta-analysis included 22 studies with a total of 1236 tic disorder patients. The mean Premonitory Urge for Tics Scale (PUTS) score was 20.17, with a 95% confidence interval of [18.14, 21.68]. Through meta-regression, we found that age and tic severity play important moderating roles in PU severity (p < 0.0001). Neuroimaging studies suggest that PU is related to the insula, prefrontal cortex (PFC), anterior cingulate cortex (ACC), and supplementary motor area (SMA), regardless of the structural or functional level.

CONCLUSIONS

Our meta-analysis confirmed the positive relationship between the severity of tics and PU and identified age as a significant factor influencing PU. The neural mechanisms underlying PU remain largely unknown, but evidence suggests that the insula, PFC, ACC, and SMA are related regions.

[Metacognitions and interoceptive sensibility in the perception of premonitory urges in tic disorders across the lifespan]

Metacognitions and interoceptive sensibility in the perception of premonitory urges in tic disorders across the lifespan Abstract. Objective: Depending on contextual factors, the prevalence of premonitory urges (PU) in patients with tic disorders (TD) increases with age and varies both intra- and interindividually. In youth, PUs correlate with metacognitions. In both youth and adults, interoceptive sensibility is altered compared to healthy controls. We examined the relationship between PUs, tics, metacognitions, and interoceptive sensibility across the lifespan regarding tic severity. Method: In an online survey, 53 participants reported their PUs on the Premonitory Urge for Tics Scale (PUTS) and tic severity on the Symptom Checklist for Tic Disorders (SBB-TIC). We assessed interoceptive sensibility via the Body Perception Questionnaire (BPQ-A) and metacognitions regarding tics with the Belief About Tics Scale (BATS). Results: Adults scored higher on the PUTS than youth. In youth, interoceptive sensibility increased with age; interoceptive sensibility correlated with PUTS. Metacognitions and interoceptive sensibility explained a significant amount of variance in premonitory urges, even after controlling for tic severity and age. Conclusions: The presumed cause of age-dependent development of PUs in youth lies in their neurophysiological maturing processes. However, negative metacognitions and interoceptive abilities also play an important role in the development and maintenance of PU and might be of therapeutic use in the treatment of TD.

Urge intolerance predicts tic severity and impairment among adults with Tourette syndrome and chronic tic disorders

BACKGROUND

Individuals with Tourette Syndrome and Persistent Tic Disorders (collectively TS) often experience premonitory urges-aversive physical sensations that precede tics and are temporarily relieved by tic expression. The relationship between tics and premonitory urges plays a key role in the neurobehavioral treatment model of TS, which underlies first-line treatments such as the Comprehensive Behavioral Intervention for Tics (CBIT). Despite the efficacy of CBIT and related behavioral therapies, less than 40% of adults with TS respond to these treatments. Further examination of the relationship between premonitory urges, tic severity, and tic impairment can provide new insights into therapeutic targets to optimize behavioral treatment outcomes. This study examined whether urge intolerance-difficulty tolerating premonitory urges-predicted tic severity and tic-related impairment among adults with TS.

METHODS

Participants were 80 adults with TS. Assessments characterized premonitory urge, distress tolerance, tic severity, and tic impairment. We used structural equation modeling (SEM) to examine the construct of urge intolerance-comprised of premonitory urge ratings and distress tolerance ratings. We first evaluated a measurement model of urge intolerance through bifactor modeling, including tests of the incremental value of subfactors that reflect premonitory urge severity and distress tolerance within the model. We then evaluated a structural model where we predicted clinician-rated tic severity and tic impairment by the latent variable of urge intolerance established in our measurement model.

RESULTS

Analyses supported a bifactor measurement model of urge intolerance among adults with TS. Consistent with theoretical models, higher levels of urge intolerance predicted greater levels of clinician-rated tic severity and tic impairment.

CONCLUSION

This investigation supports the construct of urge intolerance among adults with TS and distinguishes it from subcomponents of urge severity and distress tolerance. Given its predictive relationship with tic severity and tic impairment, urge intolerance represents a promising treatment target to improve therapeutic outcomes in adults with TS.

Psychometric Properties of the Chinese Version of the Premonitory Urge for Tics Scale: A Preliminary Report

Premonitory urges (PUs) are sensory phenomena that immediately precede tics. The Premonitory Urge for Tics Scale (PUTS) is widely used to assess the severity of PUs, but the psychometric properties of PUTS and clinical features of PU in Chinese patients with tic disorders are still unclear. In this study, we examined the psychometric properties of the Chinese version of the PUTS in a large sample (including 367 Chinese pediatric patients with tic disorders). We found no difference in PU in different age groups. The exploratory factor analysis (EFA) of PUTS showed the emergence of four primary factors. The results of reliability and validity analyses indicated that the Chinese version showed good psychometric properties. It seemed that PU was associated with the severity of obsession symptoms in patients with tic disorders. Network analysis showed that Item 7 is a critical node for the PU, in addition to Items 1 and 4. Overall, the Chinese version of PUTS can be used in Chinese child and adolescent patients with tic disorders, particularly for patients with Tourette syndrome.

A Comprehensive Review of Tic Disorders in Children

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

The role of the cingulate cortex in the generation of motor tics and the experience of the premonitory urge-to-tic in Tourette syndrome

Tourette syndrome (TS) is a neurological disorder of childhood onset that is characterized by the occurrence of motor and vocal tics. TS is associated with cortical-striatal-thalamic-cortical circuit [CSTC] dysfunction and hyper-excitability of cortical limbic and motor regions that are thought to lead to the occurrence of tics. Individuals with TS often report that their tics are preceded by 'premonitory sensory/urge phenomena' (PU) that are described as uncomfortable bodily sensations that precede the execution of a tic and are experienced as a strong urge for motor discharge. While the precise role played by PU in the occurrence of tics is largely unknown, they are nonetheless of considerable theoretical and clinical importance as they form a core component of many behavioural therapies used in the treatment of tic disorders. Recent evidence indicates that the cingulate cortex may play an important role in the generation of PU in TS, and in 'urges-for-action' more generally. In the current study, we utilized voxel-based morphometry (VBM) techniques, together with 'seed-to-voxel' structural covariance network (SCN) mapping, to investigate the putative role played by the cingulate cortex in the generation of motor tics and the experience of PU in a relatively large group of young people with TS. Whole-brain VBM analysis revealed that TS was associated with clusters of significantly reduced grey matter volumes bilaterally within: the orbito-frontal cortex; the cerebellum; and the anterior and mid-cingulate cortex. Similarly, analysis of SCNs associated with bilateral mid- and anterior cingulate 'seed' regions demonstrated that TS is associated with increased structural covariance primarily with the bilateral motor cerebellum; the inferior frontal cortex; and the posterior cingulate cortex.

Clinical Correlates of Health-Related Quality of Life in Adults With Chronic Tic Disorder

Tics are the hallmark feature of Tourette syndrome (TS), but psychiatric and sensory symptoms are widely prevalent and increasingly recognized as core manifestations of the disorder. Accumulating evidence suggests that these psychiatric and sensory symptoms exert greater influence on quality of life (QOL) than tics themselves. However, much remains uncertain about determinants of QOL in TS due to the complexity of the clinical presentation. Here, we sought to clarify the association between health-related QOL (HRQOL) and common psychiatric and sensory symptoms in adults with TS and other chronic tic disorders. To do so, we prospectively recruited 52 patients from a tertiary care clinic to complete self-report measures assessing HRQOL (Gilles de la Tourette-Quality of Life Scale, GTS-QOL), depression (Patient Health Questionnaire-9, PHQ-9), anxiety (Generalized Anxiety Disorder Scale-7, GAD-7), obsessive-compulsive symptoms (Dimensional Obsessive-Compulsive Scale, DOCS), attention deficit hyperactivity disorder symptoms (Adult ADHD Self-Report Screening Scale for DSM-5, ASRS-V), and premonitory urge (Premonitory Urge to Tic Scale, PUTS). All participants were also administered the Yale Global Tic Severity Scale (YGTSS) to quantify tic severity. Using correlational analysis and multivariable linear regression modeling, we found that GTS-QOL score was significantly associated with scores from all other rating scales, with the exception of the PUTS. GTS-QOL was most strongly associated with PHQ-9, followed by ASRS-V, GAD-7, DOCS, and YGTSS total tic score. The regression model including these five independent variables, as well as sex, explained 79% of GTS-QOL score variance [F _(6,40) = 29.6, p < 0.001]. Specific psychiatric symptoms differentially impacted physical, psychological, and cognitive HRQOL. Systematic assessment of psychiatric comorbidities is imperative for clinical care and clinical research efforts directed at improving QOL in adults with chronic tic disorders.

Different responses of repetitive behaviours in juvenile and young adult mice to Δ9 -tetrahydrocannabinol and cannabidiol may affect decision making for Tourette syndrome

BACKGROUND AND PURPOSE

Medicinal cannabis is in increasing use by patients with Tourette syndrome, a neuropsychiatric disorder that affects about 1% of the general population and has a childhood onset. However, the pharmacological effects of Δ⁹ -tetrahydrocannabinol (Δ⁹ -THC) and cannabidiol (CBD) have not been systematically screened or compared between juvenile and young adult rodents in a model of Tourette syndrome.

EXPERIMENTAL APPROACH

The administration of 2,5-dimethoxy-4-iodoamphetamine (DOI) increases head twitch response (HTR) and ear scratch response (ESR) and has been proposed as an animal model useful to respectively study motor tics and premonitory urges associated with tic disorders.

KEY RESULTS

Comparing the potency of Δ⁹ -THC to inhibit DOI-induced repetitive behaviours, the rank order was ESR > grooming > HTR versus ESR = grooming > HTR in young adult versus juvenile mice. Δ⁹ -THC (5 mg·kg^-1 ) induced severe adverse effects in the form of cataleptic behaviour in control mice and significantly increased ESR in juveniles. The pharmacological effects of CBD have not been studied in models of Tourette syndrome. In juveniles, CBD had no effect on DOI-induced ESR and grooming behaviours. CBD alone induced side effects, significantly increasing the frequency of HTR in juveniles and young adults.

CONCLUSION AND IMPLICATIONS

Δ⁹ -THC efficaciously reverses peripheral but not central motor tics. Δ⁹ -THC may reduce ambulatory movements and evoke premonitory urges in some paediatric patients. The small "therapeutic window" in juveniles suggests that CBD may not effectively treat motor tics in children and may even exacerbate tics in a population of patients with Tourette syndrome.

Gilles de la Tourette Syndrome-A Disorder of Action-Perception Integration

Gilles de la Tourette syndrome is a multifaceted and complex neuropsychiatric disorder. Given that tics as motor phenomena are the defining and cardinal feature of Tourette syndrome, it has long been conceptualized as a motor/movement disorder. However, considering premonitory urges preceding tics, hypersensitivity to external stimuli and abnormalities in sensorimotor integration perceptual processes also seem to be relevant in the pathophysiology of Tourette syndrome. In addition, tic expression depends on attention and tics can, at least partly and transiently, be controlled, so that cognitive processes need to be considered as well. Against this background, explanatory concepts should encompass not only the motor phenomenon tic but also perceptual and cognitive processes. Representing a comprehensive theory of the processing of perceptions and actions paying particular attention to their interdependency and the role of cognitive control, the Theory of Event Coding seems to be a suitable conceptual framework for the understanding of Tourette syndrome. In fact, recent data suggests that addressing the relation between actions (i.e., tics) and perceptions (i.e., sensory phenomena like premonitory urges) in the context of event coding allows to gaining relevant insights into perception-action coding in Tourette syndrome indicating that perception action binding is abnormally strong in this disorder.

Developing the Premonitory Urges for Tic Disorders Scale-Revised (PUTS-R)

BACKGROUND

Patients with Gilles de la Tourette syndrome (GTS) or chronic tic disorders frequently experience premonitory urges prior to tics. The 'Premonitory Urges for Tic Disorders Scale' (PUTS) is commonly used in order to assess urge severity in patients with tics. Several studies suggest that the PUTS might measure more than one dimension of urges. These include the quality and severity of premonitory urges.

METHODS

This study aims to replicate and extend previous findings concerning the psychometric properties of the PUTS and its underlying dimensions in a large sample of 241 patients with GTS including both adults (n = 93; mean age = 34.2 ± 12.84; 73 male) and minors (n = 148; mean age = 11.8 ± 2.86; 123 male), pooled from three different recruitment sites.

RESULTS

Data analysis confirmed good reliability across the PUTS items for both minors and adults and acceptable item characteristics for items 2-8. A factor analysis of items 1-8 confirmed the existence of two factors in both age groups.

CONCLUSIONS

The results suggest that the PUTS might benefit from several further small modifications, such as rephrasing items 1 and 9 to increase convergence with the overall construct of the scale. Finally, we propose a revised version of the PUTS, consisting of two subscales: one for urge severity and another one for urge quality by including several new items.

Premonitory Awareness Facilitates Tic Suppression: Subscales of the Premonitory Urge for Tics Scale and a New Self-Report Questionnaire for Tic-Associated Sensations

Awareness of premonitory urge in Tourette syndrome (TS) may facilitate tic suppression; however, previous studies have not supported this observation. We aimed to clarify the relationship between tic-associated sensation and tic suppression by identifying the subtypes of tic-associated sensations, including the Premonitory Urge for Tics Scale (PUTS). We developed a new questionnaire called "Rumination and Awareness Scale for tic-associated sensations" (RASTS) to assess the two additional aspects of tic-associated sensations: the intensity of somatosensory hyperawareness and the ability to identify signals of emerging tics. Sixty-two individuals with TS participated in the study (mean age = 19.2 ± 10.3 years). All participants completed the RASTS, PUTS, and Tic Suppression Scale. Of all participants, 41 were evaluated by the Yale Global Tic Severity Scale (YGTSS), while another group of 41 completed both the Leyton Obsessional Inventory-Child Version (LOI-CV) and the Tics Symptom Self-Report (TSSR). Factor analyses including nine items of the PUTS and the RASTS were conducted, and their relationships with patients' tic suppression ability were examined. The results support using RASTS for the two supposed dimensions (rumination about sensation and premonitory awareness) for assessing the two different tic-associated sensations, and PUTS for three dimensions for assessing the two types of quality of premonitory urges and intensity of premonitory urges. Premonitory awareness correlated with tic suppression ability. Conversely, rumination about sensation, PUTS total score, and the three subscales of PUTS correlated with obsessive-compulsive symptoms. In summary, being aware of signals for emerging tics facilitated self-initiated tic suppression, while ruminative tic-associated sensations did not. This study provides new insights into behavioral therapy for tics by identifying two distinct aspects of tic-associated sensations that include premonitory urges.

Controversies Surrounding the Pathophysiology of Tics

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

Aripiprazole Improves Associated Comorbid Conditions in Addition to Tics in Adult Patients with Gilles de la Tourette Syndrome

Gilles de la Tourette Syndrome (GTS) is characterized by motor and vocal tics, as well as associated comorbid conditions including obsessive-compulsive disorder (OCD), attention deficit/hyperactivity disorder (ADHD), depression, and anxiety which are present in a substantial number of patients. Although randomized controlled trials including a large number of patients are still missing, aripiprazole is currently considered as a first choice drug for the treatment of tics. The aim of this study was to further investigate efficacy and safety of aripiprazole in a group of drug-free, adult patients. Specifically, we investigated the influence of aripiprazole on tic severity, comorbidities, premonitory urge (PU), and quality of life (QoL). Moreover, we were interested in the factors that influence a patient's decision in electing for-or against- pharmacological treatment. In this prospective uncontrolled open-label study, we included 44 patients and used a number of rating scales to assess tic severity, PU, comorbidities, and QoL at baseline and during treatment with aripiprazole. Eighteen out of fortyfour patients decided for undergoing treatment for their tics with aripiprazole and completed follow-up assessments after 4–6 weeks. Our major findings were (1) aripiprazole resulted in significant reduction of tics, but did not affect PU; (2) aripiprazole significantly improved OCD and showed a trend toward improvement of other comorbidities including depression, anxiety, and ADHD; (3) neither severity of tics, nor PU or QoL influenced patients' decisions for or against treatment of tics with aripiprazole; instead patients with comorbid OCD tended to decide in favor of, while patients with comorbid ADHD tended to decide against tic treatment; (4) most frequently reported adverse effects were sleeping problems; (5) patients' QoL was mostly impaired by comorbid depression. Our results suggest that aripiprazole may improve associated comorbid conditions in addition to tics in patients with GTS. It can be hypothesized that these beneficial effects are related to aripiprazole's adaptive pharmacological profile, which exhibits an influence on the dopaminergic as well as a number of other neurotransmitter systems. For the first time, our data provide evidence that patients' decision making process for or against medical treatment is influenced by other factors than tic severity and QoL.

Convergent Validity of the PUTS

Premonitory urges are a cardinal feature in Gilles de la Tourette syndrome. Severity of premonitory urges can be assessed with the "Premonitory Urge for Tic Disorders Scale" (PUTS). However, convergent validity of the measure has been difficult to assess due to the lack of other urge measures. We investigated the relationship between average real-time urge intensity assessed by an in-house developed real-time urge monitor (RUM), measuring urge intensity continuously for 5 min on a visual analog scale, and general urge intensity assessed by the PUTS in 22 adult Tourette patients (mean age 29.8 ± 10.3 SD, 19 males). Additionally, underlying factors of premonitory urges assessed by the PUTS were investigated in the adult sample using factor analysis and were replicated in 40 children and adolescents diagnosed with Tourette syndrome (mean age 12.05 ± 2.83 SD, 31 males). Cronbach's α for the PUTS 10 was acceptable (α = 0.79) in the adult sample. Convergent validity between average real-time urge intensity scores (as assessed with the RUM) and the 10-item version of the PUTS (r = 0.64) and the 9-item version of the PUTS (r = 0.66) was good. A factor analysis including the 10 items of the PUTS and average real-time urge intensity scores revealed three factors. One factor included the average real-time urge intensity score and appeared to measure urge intensity, whereas the other two factors can be assumed to reflect the (sensory) quality of urges and subjective control, respectively. The factor structure of the 10 PUTS items alone was replicated in a sample of children and adolescents. The results indicate that convergent validity between the PUTS and the real-time urge assessment monitor is good. Furthermore, the results suggest that the PUTS might assess more than one dimension of urges, and it may be worthwhile developing different subscales of the PUTS assessing premonitory urges in terms of intensity and quality, as well as subjectively experienced control over tics and premonitory urges.

Non-Motor Aspects of Tic Disorders-New Developments

The cardinal characteristics of tic-related disorders are stereotyped motor movements and vocalizations. However, they may be accompanied by non-motor features that appear sequentially during the course of the disorder and can sometimes be more disabling than the tics themselves. This review presents our perspectives on several non-motor aspects of Tourette syndrome based on the long experience of the Neuropsychiatric Tourette Clinic of a tertiary pediatric medical center. The effect of premonitory urges, sensory modulation disorder, tic-related cognitions, and environmental conditions on the expression and intensity of tics is elaborated, with suggestions for treatment approaches to each. We also describe the mediatory effect of parental attachment style on the link between maternal stress and ticcing intensity and the need to adjust psychotherapy interventions to account for the importance of this factor in emotion regulation. This review is intended to direct attention to the non-motor aspects of Tourette syndrome. An in-depth understanding of this complex and debilitating disorder will facilitate the formulation of innovative therapeutic protocols.

Relationships between Premonitory Urge and Anxiety in Youth with Chronic Tic Disorders

Tourette's Disorder and other chronic tic disorders are common neurodevelopmental conditions. One characteristic of tic disorders is the premonitory urge, an aversive or unpleasant sensory phenomenon that may precede tics. Initial examination of premonitory urge in pediatric tic disorders suggests that awareness and experience of sensations preceding tics may be related to anxiety and OCD. However, it may be possible that specific anxiety-related symptoms, such as anxious physiologic arousal, are particularly relevant to the experience of premonitory urge. The current study examines relationships between tic-related premonitory urge and anxiety-related symptom clusters in treatment-seeking youths with a primary diagnoses of Tourette's or other chronic tic disorder. The sample consisted of 124 youth, ages 9 to 17, who participated in the multi-site Comprehensive Behavioral Intervention for Tics randomized controlled trial (CBIT; Piacentini et al., 2010). Specific anxiety-related subtypes, including generalized worry, separation, social, and panic/somatic symptoms, as well as severity of obsessions and compulsions, were assessed as potential correlates of premonitory urge. Findings indicated that age, global tic-related impairment, and specific panic/somatic symptoms accounted for a substantial proportion of variance in youth report of premonitory urge. These findings provide information about the characteristics of premonitory urge in pediatric tic disorders, and have implications for the treatment of pediatric tic syndromes.

Tourette Syndrome research highlights 2014

About 200 journal articles reported research on Tourette syndrome and other tic disorders in 2014. Here we briefly summarize a few of the reports that seemed most important or interesting, ranging from animal models to human studies. Readers can comment on our choices or provide their own favorites using the tools on the online article.

The premonitory urge to tic: measurement, characteristics, and correlates in older adolescents and adults

In addition to motor and/or vocal tics, many individuals with Tourette syndrome (TS) or chronic tic disorder (CTD) report frequent, uncomfortable sensory phenomena that immediately precede the tics. To date, examination of these premonitory sensations or urges has been limited by inconsistent assessment tools. In this paper, we examine the psychometric properties of a nine-item self-report measure, the Premonitory Urge to Tic Scale (PUTS) and examine the characteristics and correlates of the premonitory urge to tic in a clinical sample of 122 older adolescents and adults with TS or CTD. The PUTS demonstrated adequate internal consistency, temporal stability, and concurrent validity. Premonitory urges were endorsed by the majority of individuals. Most individuals reported some relief from the urges after completing a tic and being able to stop their tics even if only temporarily. Degree of premonitory urges was not significantly correlated with age, and we did not observe any gender differences. Degree of premonitory urges was significantly correlated with estimated IQ and tic severity, but not severity of comorbid obsessive-compulsive disorder or attention-deficit hyperactivity disorder. Also, it was not related to concomitant medication status. These findings represent another step forward in our understanding of the premonitory sensations associated with TS and CTD.