A randomized clinical trial of remote Group-Based comprehensive behavioral intervention for tics.

To evaluate the effectiveness of a modified four-session Comprehensive Behavioral Intervention for Tics programme for decreasing tics in children and adolescents with Tourette's syndrome. Comprehensive Behavioral Intervention for Tics programme has been shown to decrease tic severity. However, the lack of behaviour therapists in countries, such as in Taiwan, may preclude application of the standard eight-session, 10-week programme. Randomized controlled study. Participants aged 6-18years diagnosed with Tourette's syndrome or chronic tic disorder were recruited from February 2015 through September 2016. Participants in the control and intervention groups (N=23 each) received the routine care (daily pyridoxine [50mg] and psychoeducation). The intervention group received additional four behavioural intervention sessions over a 3-month period that included psychoeducation, habit reversal training, relaxation training, and education on tic relapse prevention. The outcome measures, Yale Global Tic Severity Scale scores, were assessed at before and after the completion of programme for both groups and again at 3months follow-up for the intervention group. The effect of the intervention on severity scores was assessed using a generalized estimated equation. Comparison of scores before and after intervention showed that the intervention significantly decreased the severity of total motor tics (B=-3.28, p<.01) and total tics (B=-5.86, p<.01) as compared with control treatment. YGTSS scores for the intervention group were lower at 3-month follow-up as compared with before treatment or immediately after treatment completion (total tics, p<.001). The modified four-session Comprehensive Behavioral Intervention for Tics programme was more effective than routine care for decreasing tic severity in our cohort of 6- to 18-year olds. This improvement was maintained 3months after intervention. Healthcare providers, including nurses, in countries currently not adopting Comprehensive Behavioral Intervention for Tics programme should be made aware of the positive effects of this modified intervention for Tourette's syndrome.

There is increasing evidence for the effectiveness of behavioral techniques in managing tics in youth with Tourette syndrome and tics disorders (TDs). One such intervention is Comprehensive Behavioral Intervention for Tics (CBIT), which focuses on reducing tic severity by training control and regulation. In view of the regulation deficits characteristic to TDs, in the current study, we aimed to explore the contribution of CBIT beyond tic control, to a wider expression of regulation abilities-cognitive inhibition and emotion regulation. A total of 55 participants with TDs, aged 8-15, who were randomly assigned to group-CBIT or group-Educational Intervention for Tics, were compared on cognitive inhibition tests and use of emotion-regulation strategies, pre- and post-intervention. Whereas on none of the scales a significant interactioneffect was found reflecting superiority of CBIT over EIT, repeated measures ANOVA revealed a significant time effect, with post hoc analyses indicating that cognitive inhibition and cognitive reappraisal significantly increased following CBIT intervention only. Within the group-CBIT, the increase in cognitive reappraisal was associated with higher intellectual ability. These findings may lead to a broader understanding of CBIT contribution to more than tic control, but rather to better cognitive and emotional regulation abilities.

This article describes the clinical features of Tourette syndrome and its diagnostic criteria, etiology, and pathophysiology, as well as common myths associated with tic disorders. It discusses the behavioral, pharmacologic, neuromodulation, and alternative treatment approaches to tic disorders. With the significant increase in functional ticlike behavior, especially during the COVID-19 pandemic, diagnostic criteria for functional ticlike behavior have been delineated to separate these ticlike movements from the tics observed in Tourette syndrome. Although behavioral therapy such as comprehensive behavioral intervention for tics remains the first-line treatment for tics, modifications to comprehensive behavioral intervention for tics have been developed to make this type of treatment more accessible. Pharmacologic trials for vesicular monoamine transporter 2 inhibitors have failed to meet the primary endpoint of tic reduction; however, they may still be helpful as add-on therapy for select individuals. A first-in-class compound called ecopipam met the primary endpoint for tic reduction and was well-tolerated, and may be a promising new treatment for Tourette syndrome. Deep brain stimulation may be considered for tics refractory to more conservative approaches. Tourette syndrome and tic disorders can substantially affect quality of life. Educating patients about the natural history and expected course of the disease is the most important first step in management. Choosing a treatment based on comorbidities, tic severity, and patient preference is crucial for a beneficial outcome.

Event Abstract Back to Event Improvements in Social Cognition, Executive Functioning, and Trichotillomania with Characteristics of Trichophagia in a 26-year-old Female Patient Following Neurological Rehabilitation. Trevor D. Eason1* 1 Carrick Institute, United States Presentation: A 26-year-old female patient presented with social cognitive impairment, memory decline, executive function limitations, persistent episodes of pica via trichophagia, and trichotillomania. The history included episodes of hair pulling and ingestion with no memory or recollection of the episode. Social cognition and executive functioning cues were slow and mild cognitive impairment had been made evident in the previous diagnosis. The patient stated that she had never been able to act appropriately in society after a history of multiple streptococcus A and mycoplasma pneumonia infections when she was 2 years old. The patient's mother stated that the mental processing of the patient is evident yet slower than the expected norm. Findings: During neurocognitive testing on the C3 Logix program, upon intake, Trails A time was measured at 49.1 seconds while Trails B time was measured at 55.9 seconds. Her simple reaction time was 423 milliseconds and her choice reaction time was 511 milliseconds. Her initial symptom severity score was 56% based on the associated subjective questionnaire where 0% is no symptoms. A Comprehensive Assessment of Postural Systems (CAPS®) (Pagnacco 2014) was performed assessing the patient's balance and stability, on both a solid and foamed surface, with his eyes opened, eyes closed, and with multiple head positions. Her average balance and stability score on intake was calculated as 67.12%. Comprehensive behavioral Intervention score of 23.5%. Videonystagography (VNG®) demonstrated saccadic oscillations. These eye movements were observed with similar frequency (15-20 Hz.) and equality sided to side with gaze fixation eliminated in primary position. Methods: A 12-day multi-modal neurological rehabilitation program was administered in 12 one-hour treatment sessions (Carrick, 2017). Each session consisted of neurological and vestibular rehabilitation exercises directed towards the cerebellum and basal ganglia integration, somatosensory evoked potentials, comprehensive behavioral intervention for tics (CBIT) treatment associated with habit reversal training and function-based treatments, orthoptic training, and off-vertical axis rotation (Gdowski 1999) using a multi-axis rotational chair. Based on clinical symptoms indicating alterations in energy production, she was placed on multiple nutrient formulas containing pantothenic acid (300 mg), L-α glycerylphosphorylcholine (100 mg), acetyl L-carnitine hydrochloride (25 mg), Butyric acid and calcium propionate blend (575 mg) and Huperzia serrata (75 mcg) 3 times daily. Also, the patient administered a gastrointestinal tissue repair compound containing a proprietary blend of sodium (10 mg), L-Glutamine (3.5 g), deglycyrrhizinated licorice extract (500 mg), aloe vera gel concentrate (50 mg), ginger extract (40 mg), and an enzymatic blend once daily with a meal. Outcomes: Upon discharge, Trails A time decreased to 37.6 seconds (-23.4%), and Trails B time decreased to 42.7 seconds (-23.6%). Simple reaction time decreased to 347 seconds (-18.0%), and choice reaction time decreased to 386 seconds (-24.5%). Symptom severity score decreased to 23 (-58.9%) where 0 is no symptoms. The average balance and stability score improved resulting in a score of 79.17% (+18.0%). Upon Videonystagography (VNG®), saccadic oscillation frequency was diminished per time observed with gaze stability in primary position, 20 degrees horizontally and 15 degrees vertically (circumferentially). Comprehensive behavioral Intervention score 49.8% (+111.9 %). No nystagmus was observed with gaze fixation eliminated in primary gaze position. Concurrently, the patient is now able to implement awareness strategies to compete against her trichotillomania and trichophagia episodes which ultimately proves an increase in executive functioning. Conclusions: The author suggests further investigation into the use of multi-modal neurological rehabilitation strategies, comprehensive behavioral interventions and supplemental clinical nutrition strategies for the treatment of trichotillomania with associated trichophagia, and cognitive impairment.​ The author also suggests further investigation into multi-modal, intensive approaches to improve stability scores, simple and choice reaction times, symptom severity scores and multimodal integration associated with proper neurological and cognitive function. Acknowledgements The author would like to thank and acknowledge Professor Frederick Carrick and his pioneering work in the field of clinical neuroscience. The author would also like to thank the Carrick Institute for providing the education utilized to create the multi-modal treatments implemented in this case study.

PC019 / #941 STOP-TIC STUDY: STRENGTHENING TOURETTE TREATMENT OPTIONS USING TMS TO IMPROVE CBIT: E-POSTER VIEWING

Part II of the European clinical guidelines for Tourette syndrome and other tic disorders (ECAP journal, 2011) provides updated information and recommendations for psychological interventions for individuals with tic disorders, created by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain original studies of psychological interventions for tic disorders, published since the initial European clinical guidelines were issued. Relevant studies were identified using computerized searches of the MEDLINE and PsycINFO databases for the years 2011–2019 and a manual search for the years 2019–2021. Based on clinical consensus, psychoeducation is recommended as an initial intervention regardless of symptom severity. According to a systematic literature search, most evidence was found for Habit Reversal Training (HRT), primarily the expanded package Comprehensive Behavioral Intervention for Tics (CBIT). Evidence was also found for Exposure and Response Prevention (ERP), but to a lesser degree of certainty than HRT/CBIT due to fewer studies. Currently, cognitive interventions and third-wave interventions are not recommended as stand-alone treatments for tic disorders. Several novel treatment delivery formats are currently being evaluated, of which videoconference delivery of HRT/CBIT has the most evidence to date. To summarize, when psychoeducation alone is insufficient, both HRT/CBIT and ERP are recommended as first-line interventions for tic disorders. As part of the development of the clinical guidelines, a survey is reported from ESSTS members and other tic disorder experts on preference, use and availability of psychological interventions for tic disorders.

Mindfulness-Based Interventions for Tourette Syndrome: Current Status and Future Directions

48.3 Complex Cases: Diagnostic and Behavioral Treatment Strategies in Tic-Related OCD

This chapter outlines a structured approach to assessing Tourette disorder (TD), focusing on initial evaluation and tracking progress during Comprehensive Behavioral Intervention for Tics (CBIT). It highlights critical areas for assessment, including diagnostic criteria, tic phenomenology, tic severity, and co-occurring conditions, stressing the importance of differential diagnosis to distinguish tics from similar presentations. The chapter details the use of clinical interviews, the Yale Global Tic Severity Scale (YGTSS), and self-report questionnaires to capture the multidimensional nature of tics and their impact. It emphasizes the significance of evaluating psychosocial functioning to understand the developmental, social, and occupational challenges faced by individuals with TD. Finally, the chapter underscores the necessity of systematic tracking of progress using validated tools and client feedback to ensure effective CBIT outcomes.

BackgroundIndividuals 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.MethodsParticipants 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.ResultsAnalyses 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.ConclusionThis 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.

Cognitive-behavioral treatment (CBT) is efficacious in decreasing the severity of motor and vocal tics. This chapter reviews the different CBT approaches; among them, Habit Reversal Training (HRT) and related treatments such as Comprehensive Behavioral Intervention for Tics have the most empirical support. The efficacy of HRT-based interventions was shown to be similar to that provided by some pharmacological interventions in children, adolescents, and adults with various types of tics (e.g., motor, vocal, simple, complex). Attempts to enhance HRT-based treatments by adding cognitively oriented components (e.g., cognitive therapy, acceptance work), however, have not been successful to date. Premonitory urges are very important in the tic-management strategies taught in CBT for Tourette syndrome, and changing patients’ response to them may be a key mechanism of change.

Neurocognitive correlates of treatment response in children with Tourette's Disorder

Chapter 23 - Tourette syndrome and other tic disorders of childhood

White matter alterations predict outcomes of comprehensive behavioral intervention for tics in children with Tourette syndrome: A diffusion MRI study

Reports on behavioral interventions for the treatment of Tourette’s disorder (TD) from India are limited. This patient series describes the usefulness and feasibility of conducting behavioral interventions for patients with TD from an Indian general hospital psychiatric unit. Behavioral treatments in these seven consecutively treated adult/adolescent patients with TD included all components of habit reversal treatment, comprehensive behavioral intervention for tics, and exposure with response prevention in some patients. Patients were predominantly male, with adolescent-onset severe TD, typical features and psychiatric comorbidities, and poor response to multiple medications prior to the institution of behavior therapy. In addition to long delays in diagnosis, none of the patients or their caregivers had been informed by the doctors they had consulted earlier about TD or the need for behavioral treatments before attending our center. Institution of behavioral treatments along with medications led to a 75% reduction in the severity of tics and reduction in comorbid symptoms. Patients and caregivers also reported similar rates of improvement as well as reductions in subjective distress and caregiver burden. Five patients have been followed up for seven months to seven years; apart from one patient, all others have had only minor exacerbations of tics during this period. This limited experience suggests that behavior therapies for TD can be successfully implemented in low-resource, non-specialized Indian settings. They are effective, and gains from such treatment are usually enduring.