New-onset functional tics during the COVID-19 pandemic: Clinical characteristics of 105 cases from a single centre.

BACKGROUND AND PURPOSE: The COVID-19 pandemic has been associated amongst other things with a sharp increase in adolescents and young adults presenting acutely with functional tics. Initial reports have suggested clinically relevant differences between functional tics and neurodevelopmental tics seen in primary tic disorders such as Tourette syndrome. We aimed to provide confirmatory findings from the largest single-centre cohort to date. METHODS: In the present study we present data from 105 consecutive patients who developed functional tics during a 3-year period overlapping with the COVID-19 pandemic (April 2020-March 2023). All patients underwent a comprehensive neuropsychiatric assessment at a single specialist centre for tic disorders. RESULTS: Female adolescents and young adults accounted for 69% of our sample. Functional tics had an acute/subacute onset in most cases (75% with a peak of severity within 1 month). We found a disproportionately high frequency of complex movements (81%) and vocalizations (75%). A subset of patients (23%) had a pre-existing primary tic disorder (Tourette syndrome with functional overlay). The most common psychiatric co-morbidities were anxiety (70%) and affective disorders (40%). Moreover, 41% of patients had at least one functional neurological disorder in addition to functional tics. Exposure to tic-related social media content was reported by half of the patients. CONCLUSIONS: Our findings confirm substantial clinical differences between functional tics developed during the pandemic and neurodevelopmental tics. Both patient- and tic-related red flags support the differential diagnostic process and inform ongoing monitoring in the post-pandemic era.

Self-reported impact of the COVID-19 pandemic and lockdown on young patients with tic disorders: findings from a case-control study.

BACKGROUND: Little is known about the perceived impact of the COVID-19 pandemic and subsequent lockdown measures on young patients with tic disorders. Previous studies focused on clinician and parent ratings of tic severity, whereas the only international self-report data are available for adult populations. We present the first findings from a case-control study on children and adolescents with tics during lockdown in Italy. METHODS: We surveyed 49 patients aged 6-18 years and 245 matched controls with a newly developed questionnaire covering socio-demographic and clinical data, as well as lockdown-related changes to daily life activities. RESULTS: About half (53.2%) of the Italian school-age patients who took part in our survey experienced changes in tic severity during lockdown. Perceived increases in tic severity (29.8%) were reported more often than decreases (23.4%). Analogous trends were reported for perceived restlessness and, more significantly, irritability, whereas changes in pain symptoms were less common and were similar in both directions. The presence of tics was associated with increased difficulties with remote learning (p = 0.01), but decreased feelings of missing out on social interactions with schoolmates (p = 0.03). CONCLUSIONS: Self-reported data on the impact of COVID-19 lockdown in school-age patients with tic disorders indicate perceived changes in tic severity, as well as restlessness and irritability, in about half of the cases. These findings could guide both clinicians and teachers in the implementation of targeted adjustments in the delivery of care and educational strategies, respectively.

Functional Tic-like Behaviors: From the COVID-19 Pandemic to the Post-Pandemic Era.

During the COVID-19 pandemic, there have been multiple reports about an unforeseen surge in adolescents and young adults exhibiting sudden onset functional tic-like behaviors. This phenomenon has been mainly associated with the female gender and occasionally after exposure to social media content featuring similar patterns of functional tic-like behaviors. A significant portion of these individuals have been directed to specialist clinics for movement disorders with initial misdiagnoses of late-onset refractory Tourette syndrome. Distinguishing between rapid onset functional tic-like behaviors and neurodevelopmental tics as part of Tourette syndrome can be challenging; however, the differential diagnosis is facilitated by focusing on specific clinical and demographic factors, which we have explored in a systematic literature review. Compared to neurodevelopmental tics, functional tic-like behaviors typically present with a more abrupt and intense manifestation of symptoms, onset at a later age, higher prevalence among females, inability to suppress tics, coexisting anxiety and depression, and sometimes a history of exposure to social media content portraying tic-like behaviors of a similar nature. This novel manifestation of a functional neurological disorder may thus be viewed as an emerging neuropsychiatric condition potentially triggered/exacerbated by the psychosocial repercussions of the COVID-19 crisis.

A Critical Examination of the Clinical Diagnosis of Functional Tic-like Behaviors.

BACKGROUND: Since the COVID-19 pandemic, movement disorder clinics have seen an increase in patients with an unusual type of tic-like symptoms: young adults with abrupt onset complex behaviors. It was quickly suspected that these patients suffered from functional neurological symptoms, later named Functional Tic-Like Behaviors (FTLB). Subsequent research on the differential diagnosis between FTLB and tics has been substantial and led to the development of diagnostic checklists. OBJECTIVES: We conducted a theoretical reappraisal of the FTLB literature to clarify the validity of the concept and its diagnostic implications. METHODS: This paper addresses several key aspects of the current FTLB literature: circular reasoning, the complications of the FTLB phenomenology and demographics, the impact of FTLB on tic literature at large, and issues with alignment of the FTLB concept with the diagnostic criteria for functional disorders. RESULTS: The clinical approach to FTLB might involve circular reasoning due to a lack of clinical benchmarks. The FTLB phenomenology and demographics may need more work to ensure a lack of bias and a proper description of this patient group including a clear distinction from tics. The impact of the FTLB discussion on the wider literature needs consideration. The validation of positive signs may help with both these endeavors and pave way to the inclusion of FTLB within psychiatric classification systems. Furthermore, the coexistence of FTLB and tics within the same patient needs to be addressed. CONCLUSION: More research may be needed to fully establish the diagnosis of FTLB and differentiate it from tics.

Treatment of VGKC complex antibody-associated limbic encephalitis: a systematic review.

Limbic encephalitis is an autoimmune neuropsychiatric condition characterized by subacute cognitive symptoms, seizures, and affective changes. Although limbic encephalitis is usually caused by an immune reaction secondary to neoplasms, different types of potentially treatable non-paraneoplastic limbic encephalitis (nPLE) have recently been described. In particular, published studies have reported variable responses to immunosuppressive therapy in Voltage-Gated Potassium Channel (VGKC) complex antibody-associated nPLE. This systematic literature review found that the most significant improvements were reported by patients presenting with affective symptoms and consistent neuroradiological changes. In these patients, improved clinical outcomes correlated with the largest decreases in antibody titers.

"Keep up the good work"! A case study of the effects of a specific cognitive training in Alzheimer's disease.

Alzheimer's disease (AD) is a neurodegenerative condition characterized by significant impairment in multiple cognitive domains. In recent years, the development of cognitive trainings in AD has received significant attention. In the present case study we designed a cognitive training program (GEO, Geographical Exercises for cognitive Optimization) based on an errorless paradigm and tailored to the patient's cultural interests. The aim of this training was to investigate the potential for acquiring and possibly retaining both procedural and verbal knowledge in early-stage AD. This study involved an 80-year-old female patient diagnosed with early-stage AD, and 10 matched healthy subjects. Participants were asked to perform the two GEO training tasks: a "puzzle-like" task for procedural memory, and an "association" task for verbal memory. Both the patient and the healthy controls were subsequently trained with GEO using the same two tasks for 2 months. Although the patient's performance before training in both tasks was poor compared to healthy controls, after the training these differences disappeared. Our results showed that the patient was able to acquire new procedural abilities and verbal knowledge, and that her achievements were stable at the follow-up testing scheduled 3 months after the end of the intervention. This case study suggests a potentially useful strategy for cognitive training in AD.

Behavioral adverse effects of antiepileptic drugs in epilepsy.

Patient tolerability is a significant limiting factor in the treatment of epilepsy and adverse effect profiles often determine drug retention rates. A full appreciation of the behavioral effects of a wide range of antiepileptic drugs (AEDs) is therefore essential to make informed treatment decisions. In this timely review, we highlight key alterations in mood, emotional experience, and other behavioral/psychiatric features, which can exert a crucial impact on patients' quality of life and well-being. With a view to prescribing both in general and in relation to more specific clinical characteristics, the evidence reviewed indicates that the incidence and characteristics of behavioral effects may be related to age, epilepsy type, the presence of learning disability, and previous psychiatric history. Medication parameters including dosage, titration rate, efficacy in controlling seizures, and concurrent AEDs can also contribute to the occurrence of behavioral effects. However, there are a number of limitations in drawing conclusions from the available literature. These include variation in study design, treatment group, and assessment tools that lead to difficulties comparing findings across studies, and problems with the consistency of available information relating to the study methodology. Future longitudinal studies assessing the impact of tolerance or developmental change on behavioral effects and specific studies comparing the effects of commonly prescribed agents across subgroups of patients with epilepsy will make an informative contribution to the available literature. A valuable outcome of further research may be the development of specific instruments that are sensitive to the behavioral effects associated with particular AEDs.

Impulse-control disorders in gilles de la tourette syndrome.

Impulse-control disorders (ICDs) are more common in clinic populations with Gilles de la Tourette syndrome (GTS) than in the general population. The clinical phenomenology of ICDs differ between men with GTS (who tend to be externally impulsive) and women with GTS (who tend to be internally impulsive). This article reviews the relevant literature to-date on impulsivity in GTS, with special focus on intermittent, explosive disorder, self-injurious behavior, trichotillomania, and impulsive-compulsive sexual behavior. The medical and legal community should be aware of the full spectrum of organically-based behaviors that may predispose patients with GTS to unwanted legal disciplinary action.

Pathogenic mechanisms of depression in multiple sclerosis.

Patients with multiple sclerosis (MS) have an increased risk of developing depression as compared with healthy subjects and patients with many other chronic neurological conditions. The observation that depressive symptoms can precede the onset of neurological symptoms suggests that depression may be related to early disease-specific processes. Several pathogenic mechanisms have been proposed to explain the etiology of depression in patients with MS. This article reviews the current evidence for the contribution of lesional, autoimmune, iatrogenic, and psychosocial factors. It appears that the etiology of depression is multifactorial and varies in individual patients with MS.

"Trousseau's disease:" a description of the Gilles de la Tourette syndrome 12 years before 1885.

French neurologist Georges Gilles de la Tourette first described the syndrome which earned him eponymous fame in 1885. However, a publication dated 1873 by Armand Trousseau included a detailed account of what is currently know as Gilles de la Tourette syndrome (GTS). In Gilles de la Tourette's celebrated 1885 paper, there is a brief mention of the clinical picture described earlier by Trousseau, but Gilles de la Tourette somewhat disregarded it. We present the first English translation of Trousseau's description and argue that this description is more akin to modern conceptualization of GTS than the description of Gilles de la Tourette himself.

The "imprisoned illness:" motor tic disorder in Rainer Maria Rilke's Notebooks of Malte Laurids Brigge.

Rainer Maria Rilke's novel The Notebooks of Malte Laurids Brigge contains a reference of interest for the catalog of literary portrayals of tiqueurs. In this article, we report his description of a Parisian character displaying multiple motor tic symptoms, along with a brief commentary.

Ictal consciousness in epilepsy and nonepileptic attack disorder.

Exploration of subjective experiences during seizures may enhance knowledge of the differing natures of epilepsy and nonepileptic attack disorder (NEAD). We performed a quantitative evaluation of both the general level of awareness and the specific contents of consciousness during seizures using the Ictal Consciousness Inventory (ICI). Ninety-five adult outpatients attending general neuropsychiatry and epilepsy clinics with established diagnoses of either epilepsy (n = 66) or NEAD (n = 29) completed one ICI for each witnessed seizure recalled. Patients with a dubious/dual diagnosis were excluded. ICI Level (ICI-L) and ICI Content (ICI-L) scores were calculated for the 167 questionnaires generated by patients with epilepsy (n = 119, of which 58 from patients with temporal lobe epilepsy, 14 frontal lobe epilepsy, and 47 idiopathic 30 generalized epilepsy) and patients with NEAD (n = 48). Mann-Whitney U tests revealed statistically significant higher ICI-L and ICI-C scores for patients with NEAD (both P = 0.01). Subjective reports of consciousness experiences varied between epilepsy and NEAD, with patients with NEAD reporting significantly greater levels of general awareness/responsiveness and more vivid subjective experiences during attacks. The ICI is proposed as a potentially useful self-report instrument to supplement clinical and instrumental tests for the differential diagnosis of epilepsy and NEAD.

The prevalence of psychiatric disorders in epilepsy: a critical review of the evidence.

Psychopathology has long been associated with epilepsy and should not be overlooked as it could exacerbate the epilepsy itself and impair the health-related quality of life of sufferers. A higher prevalence of psychiatric disorders has frequently been demonstrated amongst patients with epilepsy compared both with the general population and with individuals presenting neurological or non-neurological conditions. This review critically evaluates selected studies on the prevalence of psychiatric disorders in epilepsy patients compared with the general population and controls. Heterogeneity exists across the research methodologies, therefore further research, using less selected groups, should be undertaken to allow valid comparisons and the identification of more precise prevalence rates.

The prevalence and clinical characteristics of pathological gambling in Parkinson's disease: an evidence-based review.

Large prospective studies in the USA and Canada have estimated the prevalence of pathological gambling (PG) in the general population at 0.43% and 1% respectively. Studies using equivalent methodology in patients with Parkinson's disease (PD) have reported markedly higher prevalence rates. A total of 1032 patients with PD have been included in clinical studies in North America, Great Britain and Italy. Of these, 3.2% met diagnostic criteria for PG. The prevalence of PG was found to be higher in men than in women with PD, although the difference was not statistically significant. A younger age at onset of PD, increased novelty-seeking behaviour and a history of alcohol misuse have been found to be associated with PG in this population. Pathological gambling has been associated with dopamine agonist use, and the prevalence of the association has been found to be 5.7% in patients with PD. Although the literature suggests a high incidence of psychiatric co-morbidity, particularly depression and other impulse control disorders, this is yet to be confirmed by case-control studies.

The behavioral spectrum of Gilles de la Tourette syndrome.

Gilles de la Tourette syndrome is a neurodevelopmental disorder consisting of multiple motor and one or more vocal/phonic tics. Tourette's syndrome is increasingly recognized as a common neuropsychiatric disorder usually diagnosed in early childhood, and comorbid neuropsychiatric disorders occur in approximately 90% of patients; the most common of these are attention deficit hyperactivity disorder and obsessive-compulsive disorder. Depression is also common, with a lifetime risk of 10% of patients. Moreover, a high prevalence of personality disorders has been reported in preliminary investigations on Tourette's syndrome populations. This paper provides an updated review of the literature on the multifaceted phenotype of Tourette's syndrome, with special attention to the behavioral problems and the relationship between Tourette's syndrome and comorbid neuropsychiatric conditions. The issue of whether Tourette's syndrome should still be considered as a unitary nosological entity is also addressed.

Depression in women with epilepsy: clinical and neurobiological aspects.

Patients affected by epilepsy show a considerably higher incidence of depression compared with the general population. Since women are twice as likely as men to suffer from depression, female gender could be considered a major risk factor for developing this condition. Converging lines of evidence suggest that sex hormones, which are known to contribute to remodelling the hippocampus, play a pivotal role in both epilepsy and depression. In women, the role of sex hormone levels may be more important because of their physiological cyclic fluctuations. Oestrogens, more than other ovarian hormones, show an effect similar to antidepressant drugs by stimulating hippocampal synaptogenesis, thus exerting a protective role against seizures as well. This paper reviews the current knowledge on the neurobiological basis of depression in women with epilepsy. The emerging picture informs therapeutic strategies to improve the clinical management of this common comorbidity.

Brain mechanisms underlying the placebo effect in neurological disorders.

The potential of placebo treatments to alleviate a variety of medical conditions has long been recognised. Although the placebo effect is widely known, the physiological mechanisms underlying this phenomenon are not well understood. This review focuses on the existing evidence for placebo responses in different neurological conditions, including pain, Parkinson's disease, depression, sleep and immune-mediated disorders. Special attention is paid to the neural changes associated with placebo treatments, as revealed by in vivo neurophysiological and functional neuroimaging studies. Converging evidence suggests that placebo analgesia is linked to the activation of the endogenous opioid analgesia network, whilst dopaminergic pathways seem to play a central role in the placebo effect in movement disorders and neuroimmunomodulation. Further research on the placebo response is needed, both to improve the efficacy of its application in clinical practice and to shed more light on the complexity of mind-body interactions.

The "bicameral mind" 30 years on: a critical reappraisal of Julian Jaynes' hypothesis.

In 1976 Julian Jaynes published his controversial book The Origins of Consciousness in the Breakdown of the Bicameral Mind, introducing the hypothesis of a two-chambered brain-mind model that preceded the evolutionary development of the conscious mind. Jaynes' speculative model gave rise to a huge debate, which has reverberated throughout the current neuroscientific and neurophilosophical literature. Has the bicameral mind stood the test of time? To answer this question, the present paper adopts a multidisciplinary perspective and, after briefly summarizing Jaynes' hypothesis, addresses two main critical issues: the neurological basis of the bicameral model and the philological accuracy of Jaynes' arguments. Finally, the concept of a non-unitary Self is presented as one of the most relevant contemporary legacies of the bicameral mind.