Neurocognitive predictors of treatment response to randomized treatment in adults with tic disorders.

Tourette's disorder (TS) and chronic tic disorder (CTD) are neurodevelopmental disorders characterized by involuntary vocal and motor tics. Consequently, TS/CTD have been conceptualized as disorders of cognitive and motor inhibitory control. However, most neurocognitive studies have found comparable or superior inhibitory capacity among individuals with TS/CTD relative to healthy controls. These findings have led to the hypothesis that individuals with TS/CTD develop increased inhibitory control due to the constant need to inhibit tics. However, the role of cognitive control in TS/CTD is not yet understood, particularly in adults. To examine the role of inhibitory control in TS/CTD, the present study investigated this association by assessing the relationship between inhibitory control and treatment response in a large sample of adults with TS/CTD. As part of a large randomized trial comparing behavior therapy versus supportive psychotherapy for TS/CTD, a battery of tests, including tests of inhibitory control was administered to 122 adults with TS/CTD at baseline. We assessed the association between neuropsychological test performance and change in symptom severity, as well as compared the performance of treatment responders and non-responders as defined by the Clinical Global Impression Scale. Results indicated that change in symptoms, and treatment response were not associated with neuropsychological performance on tests of inhibitory control, intellectual ability, or motor function, regardless of type of treatment. The finding that significant change in symptom severity of TS/CTD patients is not associated with impairment or change in inhibitory control regardless of treatment type suggests that inhibitory control may not be a clinically relevant facet of these disorders in adults.

Long-term follow-up of pallidal Deep Brain Stimulation in teenagers with refractory Tourette syndrome and comorbid psychiatric disorders: About three cases.

OBJECTIVES: Tourette syndrome (TS) is a complex neuropsychiatric disorder associated with comorbid psychiatric disorders. Peak of tic severity typically occurs in early adolescence and impacts quality of life. Since 1999, promising therapeutic effects of Deep Brain Stimulation (DBS) have been reported in tic reduction for adults with refractory TS. The aim of the study was to assess the long-term risk-benefit ratio of pallidal DBS for young patients with refractory TS and severe comorbid psychiatric disorders. METHODS: We retrospectively assessed the long-term clinical outcomes of three adolescents who underwent pallidal DBS for the treatment of refractory TS. RESULTS: The mean duration of follow-up was 52 months in our case series. We observed that motor tics decreased with posteroventral GPi DBS in all patients, without reaching a continuous significance over the long-term follow-up. Self-reported social inclusion was globally improved, despite lack of efficacy of DBS on comorbid conditions. CONCLUSIONS: These findings suggest a long-term therapeutic benefit of early DBS intervention for highly socially impaired young patients suffering from intractable TS with severe comorbid psychiatric conditions. Further studies are needed to determine the most effective targets of DBS on both tics and comorbid psychiatric profile of TS.

Cognitive-behavioral therapy induces sensorimotor and specific electrocortical changes in chronic tic and Tourette's disorder.

BACKGROUND: Tic disorders, such as the Gilles de la Tourette syndrome and persistent tic disorder, are neurodevelopmental movement disorders involving impaired motor control. Hence, patients show repetitive unwanted muscular contractions in one or more parts of the body. A cognitive-behavioral therapy, with a particular emphasis on the psychophysiology of tic expression and sensorimotor activation, can reduce the frequency and intensity of tics. However, its impact on motor activation and inhibition is not fully understood. METHODS: To study the effects of a cognitive-behavioral therapy on electrocortical activation, we recorded the event-related potentials (ERP) and lateralized readiness potentials (LRP), before and after treatment, of 20 patients with tic disorders and 20 healthy control participants (matched on age, sex and intelligence), during a stimulus-response compatibility inhibition task. The cognitive-behavioral therapy included informational, awareness training, relaxation, muscle discrimination, cognitive restructuration and relapse prevention strategies. RESULTS: Our results revealed that prior to treatment; tic patients had delayed stimulus-locked LRP onset latency, larger response-locked LRP peak amplitude, and a frontal overactivation during stimulus inhibition processing. Both stimulus-locked LRP onset latency and response-locked LRP peak amplitude normalized after the cognitive behavioral therapy completion. However, the frontal overactivation related to inhibition remained unchanged following therapy. CONCLUSIONS: Our results showed that P300 and reaction times are sensitive to stimulus-response compatibility, but are not related to tic symptoms. Secondly, overactivity of the frontal LPC and impulsivity in TD patients were not affected by treatment. Finally, CBT had normalizing effects on the activation of the pre-motor and motor cortex in TD patients. These results imply specific modifications of motor processes following therapy, while inhibition processes remained unchanged. Given that LRPs are partially generated within the sensorimotor and supplementary motor area, the reported reduction in tic frequency and improvements of LRPs components suggest that CBT induced a physiological change in patients' motor area.

The application and efficacy of combined neurofeedback therapy and imagery training in adolescents with Tourette syndrome.

We aimed to examine the effectiveness of combined neurofeedback therapy and imagery training in adolescent patients with refractory Tourette syndrome. Two patients, aged respectively 14 and 16 years, had been treated with haloperidol and tiapride; however, this medication was ineffective and accompanied by intolerable side effects. In this study, the patients completed 80 sessions of neurofeedback treatment followed by imagery training. The patients were assessed with behavior rating scales both before and after the treatment as well as during follow-up examinations to evaluate the effect of the combined therapy. Patients showed significant improvement in motor tic and vocal tic symptoms, exemplified by a reduction in the frequency and intensity of tics, indicating that neurofeedback, together with imagery training, has a positive therapeutic effect on adolescent patients with medication-refractory Tourette syndrome.

The effects of awareness training on tics in a young boy with Tourette syndrome, Asperger syndrome, and attention deficit hyperactivity disorder.

Previous research has shown habit reversal training (HRT) to be effective in reducing tics. In some studies, tics have been reduced by implementing only a few components of HRT. The current study investigated the first step, awareness training, for treating tics in a young boy with Asperger syndrome, Tourette syndrome, and attention deficit hyperactivity disorder. The results showed a reduction in all tics.

Current controversies on the role of behavior therapy in Tourette syndrome.

Comprehensive behavioral intervention for tics (CBIT) is a safe and effective treatment for managing the tics of Tourette syndrome (TS). In contrast to most current medications used for the treatment of tics, the efficacy of CBIT has been demonstrated in 2 relatively large, multisite trials. It also shows durability of benefit over time. Similar to psychopharmacological intervention, skilled practitioners are required to implement the intervention. Despite concerns about the effort required to participate in CBIT, patients with TS and parents of children with TS appear willing to meet the requirements of the CBIT program. Efforts are under way to increase the number of trained CBIT providers in the United States. Based on available evidence, recent published guidelines suggest that CBIT can be considered a first-line treatment for persons with tic disorders. © 2013 Movement Disorder Society.

Report of a deaf child with Tourette's disorder.

This is a case study of a deaf child with Tourette's Disorder (TD). Hearing parents and mental health clinicians unfamiliar with typical behaviors of deaf children may have difficulties differentiating the clinical presentation of symptoms of TD from the effects of deafness, as well as in implementing appropriate interventions. This case study reports the history, symptoms, diagnostic process, and treatment interventions. This is relevant for furthering the clinical knowledge of mental health professionals working with Deaf, deaf, and hard-of-hearing children and adolescents.

Pharmacological treatment of Gilles de la Tourette syndrome.

Pharmacological treatment is usually indicated in moderate to severe tics in psychosocial and/or functional impairment. Neuroleptics with D2 antagonistic activity remain the cornerstone of anti-tic therapy. Lack of randomized controlled clinical trials base therapeutic decisions mainly on clinical expertise and common sense. Recently, aripiprazole has emerged as the neuroleptic with the most advantageous efficacy/side effect ratio for treating tics. Yet, in non-responders to aripiprazole, many neuroleptic and non-neuroleptic drugs, including botulinum toxin injections, are available and often successful. Apart from conducting methodologically sound trials (which includes sufficiently long observation periods), future efforts in the field should test the combination of cognitive-behavioral therapy with drugs or of multi-drug therapy as well as the development of biomarkers (endophenotypes) to monitor and even predict treatment response.

Habit reversal training for children with tourette syndrome: update and review.

TOPIC: Habit reversal training (HRT) is emerging as an efficacious behavioral intervention for Tourette syndrome in children and adults. PURPOSE: The purpose of this article is to review the recent literature investigating the efficacy of HRT for treating children with chronic tic disorders. SOURCES: This review examines single-subject design studies and randomized, controlled trials of HRT conducted in children with chronic tic disorders since 2000. CONCLUSIONS: Intervention built on HRT appears to be effective for decreasing tic severity in children and adolescents. Results from a recent multisite trial suggest that incorporation of functional analysis may enhance the effectiveness of traditional HRT.

A phenomenological investigation of women with Tourette or other chronic tic disorders.

There are little data concerning clinical characteristics of women with Tourette disorder and chronic tic disorders in the extant literature and what is available mostly focuses on treatment-seeking individuals. The present research was conducted to provide a phenomenological characterization of tic disorders among 185 adult women with tic disorders. In addition to providing a descriptive overview of specific tic symptoms, tic severity, self-reported history of other psychiatric conditions, and impairment/lifestyle impact due to tics, this study compares 185 women and 275 men between 18 and 79 years old with tic disorders (who completed an identical battery of measures) based on demographic, social/economic status indicators, psychiatric variables (comorbidity, family psychiatric history, symptom presentation), adaptive functioning/quality of life, and impairment variables among a nonclinical adult sample. Finally, this research examines the relationship between tic severity and impairment indicators among women with tics. Sixty-eight percent of women in our sample reported severe motor tics and 40% reported severe phonic tics. Our exploratory data suggest that a sizeable number of adult women with persistent tics are suffering from psychiatric comorbidity and psychosocial consequences such as underachievement and social distress. Tic severity in women may be associated with lifestyle interference as well as with symptoms of depression and anxiety, and such symptoms may be more common among women with tics than in men with tics.

[Effects of habit reversal training in children with chronic tic disorder - a pilot study]. / Die Wirksamkeit der Reaktionsumkehr-Behandlung bei Kindern und Jugendlichen mit chronischen Tic-Störungen.

OBJECTIVE: The present pilot study investigates the effects of habit reversal training in a German speaking population of children and young adults with chronic tic disorders using a new treatment program where the interventions are based on a manualized cognitive-behavioral program. METHODS: 16 children were treated using the program. Tic-symptoms were assessed using direct observation as well as parent, self and clinical ratings. The efficacy of an intense cognitive-behavioral therapy phase was compared with a minimal intervention phase. The statistical analysis focused on different parameters in the therapy. RESULTS: We obtained positive results for the acceptance and efficacy of the program. CONCLUSIONS: These first findings indicate the new developed program is useful. Further studies are necessary to prove the efficacy of the interventions.

Evaluation of two instruction methods to increase employment options for young adults with autism spectrum disorders.

We evaluated the efficacy of a vocational training program including behavioral skills training, and a "performance cue system" (i.e., a proprietary iPhone application adapted for the study) to teach targeted social-vocational skills to six young adults with an Autism Spectrum Disorder. In two separate studies, participants were employed to assist in the delivery of a fire safety education program. Participants were asked to wear an inflatable firefighter WalkAround® mascot costume and to perform 63 scripted behaviors in coordination with a fire prevention specialist who was the lead program presenter. In Study 1, three participants were initially exposed to established company training procedures comprised of behavioral skills training components to determine whether they met mastery of the skills. If necessary to reach criteria, participants were then exposed to a performance cue system. In Study 2, three additional participants were provided with the performance cue system alone, and then behavioral skills training if required. A single case, multiple-baseline design across subjects was used to evaluate efficacy of each intervention. Results indicate that 5 of 6 participants reached criterion only after introduction of the cue system while the sixth reached criterion with behavioral skills training alone. The program received high satisfaction ratings from participants, their parents, and consumers. Implications and potential use of the PCS in other employment settings are discussed.

[The development of deep brain stimulation as a putative treatment for resistant psychiatric disorders]. / Die Entwicklung der tiefen Hirnstimulation bei der Behandlung therapieresistenter psychiatrischer Erkrankungen.

Since approximately 10 years investigations have been carried out on the impact of deep brain stimulation (DBS) of treatment-resistant obsessive-compulsive disorders and depression. New fields of application are for Tourette's syndrome, substance abuse, dementia and anxiety. New functional, structural and molecular data have led to a new conceptualization of these disorders as dysfunctions of networks which process motivational and affective stimuli. DBS permits the selective and basically reversible modulation of such networks. So far adverse effects have been graded as marginal. In the field of treatment-resistant obsessive-compulsive disorders and depressive disorders uncontrolled studies have been published with initial satisfactory and concordant indications of the therapeutic effect of DBS in a variety of target areas of the brain. It is most important to provide a consistent interdisciplinary and durable development of concepts for a responsible use of DBS in patients with psychiatric disorders. Only in this way can the potentially most interesting therapeutic development of clinical psychiatry of the last 20 years be continued uninterrupted.

Vertical gaze palsy after thalamic stimulation for Tourette syndrome: case report.

OBJECTIVE: We describe a patient who developed a vertical gaze paralysis after deep brain stimulation performed for intractable Tourette syndrome due to a small deep bleeding in the upper mesencephalon. CLINICAL PRESENTATION: A 39-year-old man underwent thalamic deep brain stimulation for intractable Tourette syndrome. Immediately postoperatively, he had diplopia and dizziness. The neurological examination revealed vertical gaze palsy with preserved vertical oculocephalic movements. A postoperative computed tomography scan revealed a discrete high-density lesion across the midline at the distal end of the left electrode. This area corresponds with the pretectal area, including the rostral interstitial nucleus of the medial longitudinal fasciculus, with sparing of the oculomotor and rubral nuclei. INTERVENTION: Six months postoperatively, maximal upward and downward smooth pursuit eye movements were achieved. Upward saccadic velocities were still reduced by 20 to 25 degrees. CONCLUSION: This case report describes a complication that might demand special attention during the planning of thalamic deep brain stimulation for the treatment of Tourette syndrome. Examination of both horizontal and vertical eye movements during deep brain stimulation surgery is recommended.

Estudo de caso: atendimento em terapia ocupacional de um paciente com síndrome de Tourette / Case study: occupational therapy for a patient with Tourett's syndrome

O trabalho envolve a observação e análise do uso de atividades terapêuticas no atendimento em terapia ocupacional de um paciente do sexo masculino, com 12 anos de idade, portador da síndrome de Tourette, buscando verificar a influência do tratamento em sua evolução clínica, através de instrumentos de avaliação...

The work imply a observation and analyze of therapeutics activities in occupation therapeutic attendment for a patient, 12 years old, with Tourett's syndrome, searching verify the infusion of treatment in his clinic evolution, by the evaluation instruments, clinic observation, movies, and attendment's accompaniment made by a occupational therapist...

The effect of Tourette syndrome on the education and social interactions of a school-age child.

Tourette syndrome is a neurological condition characterized by involuntary vocal or motor tics. Symptoms begin occurring before the age of 18 and are more common in boys than girls. Tics can change in severity and character from hour to hour or in stressful situations. Uncontrolled tics can cause self-esteem concerns, family stress, and academic difficulty. Medication and school services were employed to help the student achieve the goal of feeling more comfortable with peers and in the classroom.

[Investigation of childhood neuropsychiatric disorders in adults often desirable. Functional disabilities can result in social maladjustment]. / Utredning av barnneuropsykiatriska tillstånd hos vuxna ofta önskvärd. Funktionshindren kan leda till social missanpassning.

So-called child neuropsychiatric disorders (ADHD/DAMP, autism spectrum disorders, Tourette's syndrome) are being recognized with increasing frequency in child and adolescent psychiatry. Through follow-up studies, case reports and autobiographical accounts it has become evident that these disorders often persist into adulthood, and the need for diagnostic evaluation of adults is increasing. The Neuropsychiatric Diagnostic Team for Adults in Lund, Sweden, was established in 1998 to meet this need. 228 adults, mostly 18-30 years old, have completed the diagnostic process, resulting in one of the above-mentioned diagnoses in 64%. 80 patients had ADHD/DAMP, 59 had autism spectrum disorders and 7 had Tourette's syndrome. The diagnostic process involves clinical interviews and observation, neuropsychological evaluation and, if possible, a parent interview. So far, the impact on quality of life of a child neuropsychiatric diagnosis received in adulthood is not known. Follow-up studies are needed.

[Gilles de la Tourette syndrome. Effect of nicotine, alcohol and marihuana on clinical symptoms]. / Gilles de la Tourette-Syndrom. Einfluss von Nikotin, Alkohol und Marihuana auf die klinische Symptomatik.

Gilles de la Tourette syndrome (TS) is a neuropsychiatric spectrum disorder of unknown etiology. While several studies have provided evidence that nicotine causes an improvement, only anecdotal reports suggest that alcohol and marijuana influence the symptomatology. Using a structured interview, we questioned a larger group of patients with Tourette syndrome (n = 47) about the use of nicotine, alcohol, and marijuana and their subjective experiences. Of 28 smoking patients only 2 (7%) reported a tic reduction when smoking. Of 35 patients drinking alcohol 24 (69%) noted an improvement. Thirteen patients reported the use of marijuana, of whom 11 (85%) noted a marked improvement. Our results provided strong evidence that the use of both alcohol and marijuana causes much more improvement in TS than nicotine smoking. We suggest that marijuana influences an assumed interaction between cannabinoid and dopamine receptors and, by this, influences the dopaminergic processes in basal ganglia and motor activity.

Traumatic war experiences affect outcome in a case of Tourette's syndrome.

BACKGROUND: Stress has been associated with the course of Tourette's syndrome (TS). METHODS: The case report presented aims to emphasize the effect a severe traumatic experience has on the expression of TS. RESULTS: Following an intense traumatic experience, combat-related, a relatively mild case of TS became intractable. CONCLUSION: The combination of both of these severe, sometimes refractory, disorders is rare, and poses a therapeutic challenge.

Gilles de la Tourette disorder among individuals with severe or profound mental retardation.

There have been limited reports on the incidence of Gilles de la Tourette disorder among individuals with mental retardation. Only three cases have been reported in people with severe or profound mental retardation. In this paper three additional case reports of people with severe or profound mental retardation and Tourette disorder were presented. Issues related to the diagnosis of Tourette disorder in this population were discussed.