Association between body mass index and tic disorders in school-age children.

OBJECTIVE: To explore the relationship between body mass index (BMI ) and the severity of tic disorders (TDs) in children 6-14 years old. METHODS: A total of 86 children diagnosed with TDs in a hospital between Jan. 2023 and Sept. 2023 were collected by convenient sampling method, and the general data and TD-specific data were collected and analyzed. RESULTS: Univariate analysis showed that patients with different Yale Global Tic Severity Scale (YGTSS) grades had statistically significant differences in age, BMI, residence, snacking pattern, weekly physical exercise frequency, weekly physical exercise time, and proportion of cesarean birth. Multiple linear regression analysis showed that the YGTSS score grades were related to BMI, snacking pattern, and cesarean birth of the patients. Correlation analysis revealed a positive correlation between BMI grades and the YGTSS score grades, with a higher BMI indicating more severe TDs. Predictive value evaluation showed that BMI, snacking pattern, and cesarean birth had predictive values for TD severity, and the highest value was found in the combined prediction. CONCLUSION: BMI, snacking pattern, and cesarean birth are of predictive values for the severity of TDs. In addition, BMI is positively correlated with the severity of TDs, and a higher BMI suggests more severe TDs.

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.

What are the Key Phenomenological Clues to Diagnose Functional Tic-Like Behaviors in the Pandemic Era?

BACKGROUND: Functional tic-like behaviors (FTLBs) can be difficult to distinguish from tics. OBJECTIVES: To describe the phenomenology of FTLBs in youth and assess the movements and vocalizations most suggestive of the diagnosis. METHODS: We compared the phenomenology of tics between youth (<20 yr) with FTLBs and with primary tics from our Registry in Calgary, Canada. RESULTS: Two hundred and thirty-six youths were included: 195 with primary tics (75% males; mean age: 10.8 yr) and 41 with FTLBs (98% females; 16.1 yr). In the bivariate models, FTLBs were most associated with copropraxia (OR = 15.5), saying words (OR = 14.5), coprolalia (OR = 13.1), popping (OR = 11.0), whistling (OR = 9.8), simple head movements (OR = 8.6), and self-injurious behaviors (OR = 6.9). In the multivariable model, FTLBs were still associated with saying words (OR = 13.5) and simple head movements (OR = 6.3). Only 12.2% of youth with FTLBs had throat clearing tics (OR = 0.2). CONCLUSIONS: This study shall help physicians diagnose youth with FTLBs according to the presence/association of specific movements and vocalizations.

Prevalence and influencing factors of sleep problems in tic disorders: a meta-analysis.

BACKGROUND: Sleep problems are commonly observed in patients with tic disorders. Nevertheless, studies have demonstrated a wide variation in the prevalence of sleep disturbances among this population. Consequently, it remains ambiguous whether sleep issues are inherently characteristic of tic disorders or are influenced by external factors. METHODS: We conducted a comprehensive search across various databases and performed a meta-analysis to determine the prevalence of sleep problems in tic disorders. Additionally, we assessed pre-existing comorbidities and associated characteristics using meta-regression analysis. RESULTS: After including 33 studies in the final meta-analysis, we found that the pooled prevalence of sleep problems in tic disorders was 34% (95%CI: 26% to 43%). Meta-regression analysis revealed that the presence of co-occurring symptoms of ADHD (p < 0.05), obsession compulsive disorder/behaviours (p < 0.05), anxiety (p < 0.001), and mood disorders (p < 0.001) was associated with an increased likelihood of experiencing sleep problems. CONCLUSIONS: Our findings consistently indicate that individuals with tic disorders frequently encounter significant sleep problems. This underscores the importance of routinely screening for sleep problems during clinical assessments. Effectively managing sleep problems in patients with tic disorders is crucial not only for the well-being of the patients themselves but also for their families.

Co-morbid tics and stereotypies: a systematic literature review.

BACKGROUND: Tics and stereotypies are childhood-onset repetitive behaviours that can pose significant diagnostic challenges in clinical practice. Both tics and stereotypies are characterised by a complex co-morbidity profile, however little is known about the co-occurrence of these hyperkinetic disorders in the same patient population. OBJECTIVE: This review aimed to assess the relationship between tics and stereotypies when these conditions present in co-morbidity. METHODS: We conducted a systematic literature review of original studies on co-morbid tics and stereotypies, according to the standards outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Our literature search identified six studies of suitable sample size (n ≥ 40) presenting data on the association between tics and stereotypies in otherwise typically developing patients. A considerable proportion (23%) of patients diagnosed with stereotypic movement disorder present with co-morbid tics (range 18-43%). Likewise, the prevalence of primary stereotypies is increased in patients with tic disorders such as Tourette syndrome (8%, range 6-12%). DISCUSSION: Tics and stereotypies can often develop in co-morbidity. The association of tics and stereotypies in the same patient has practical implications, in consideration of the different treatment approaches. Future research should focus on the assessment and management of both conditions, particularly in special populations (e.g. patients with pervasive developmental disorders).

Automated Quantification of Eye Tics Using Computer Vision and Deep Learning Techniques.

BACKGROUND: Tourette syndrome (TS) tics are typically quantified using "paper and pencil" rating scales that are susceptible to factors that adversely impact validity. Video-based methods to more objectively quantify tics have been developed but are challenged by reliance on human raters and procedures that are resource intensive. Computer vision approaches that automate detection of atypical movements may be useful to apply to tic quantification. OBJECTIVE: The current proof-of-concept study applied a computer vision approach to train a supervised deep learning algorithm to detect eye tics in video, the most common tic type in patients with TS. METHODS: Videos (N = 54) of 11 adolescent patients with TS were rigorously coded by trained human raters to identify 1.5-second clips depicting "eye tic events" (N = 1775) and "non-tic events" (N = 3680). Clips were encoded into three-dimensional facial landmarks. Supervised deep learning was applied to processed data using random split and disjoint split regimens to simulate model validity under different conditions. RESULTS: Area under receiver operating characteristic curve was 0.89 for the random split regimen, indicating high accuracy in the algorithm's ability to properly classify eye tic vs. non-eye tic movements. Area under receiver operating characteristic curve was 0.74 for the disjoint split regimen, suggesting that algorithm generalizability is more limited when trained on a small patient sample. CONCLUSIONS: The algorithm was successful in detecting eye tics in unseen validation sets. Automated tic detection from video is a promising approach for tic quantification that may have future utility in TS screening, diagnostics, and treatment outcome measurement. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Incidence trend and epidemiology of tic disorders among youths and adults in Korea from 2003 to 2020: A national population-based study.

Tic disorder is a highly prevalent neurodevelopmental disorder; however, research on its incidence trends is still rare. We aimed to investigate its annual incidence rates and the characteristics of incident cases in the general Korean population using data from the National Health Insurance Service-National Health Information Database as a proxy measurement for true incidence in the community. The total number of incident cases and incidence rates of tic disorders from 2003 to 2020 were compared between youths and adults. Both the number of incident cases and the annual incidence rates of tic disorders significantly increased from 2003 to 2020. The overall increasing trend in the incidence rates was significantly greater in youths than in adults; however, the incidence rates in adults showed a relatively recent increase. The male predominance regarding the newly diagnosed case number in youths was no longer observed in adults. Tic disorders occurred more commonly in the low-income group than in the high-income group. Neurodevelopmental comorbidities in youths and mood or anxiety disorders and schizophrenia in adults were more frequently observed. Antipsychotic medication adherence was higher in youths than in adults. Efforts are required to raise awareness and promote expert education for adult patients with tic disorders.

Cytokine levels reflect tic symptoms more prominently during mild phases.

Tic disorder is a neuropsychiatric condition that affects 3% of all children and can have a significant impact on their quality of life. Cytokines, interferons, interleukins, lymphokines, and tumor necrosis factors are involved in the neuroinflammatory circuitry of tic disorders. This study aimed to identify the cytokines involved in the pathogenesis of tic disorders. We enrolled 44 patients with tic disorder and 38 healthy controls. Patients were free of psychotropic medications for at least 3 weeks. Whole blood samples were analyzed using a Luminex® human cytokine multiplex assay kit. Patients were divided into groups with "mild tics" and "above moderate tics" based on Yale Global Tic Severity Scale (YGTSS) scores for comparison. The final analysis included 35 patients (28 male and 7 female) and 31 controls (20 male and 11 female). In the mild tic group, interleukin (IL)-12 p70 negatively correlated with motor tic scores. Granulocyte-macrophage colony-stimulating factor, IL-4, IL-8, and tumor necrosis factor (TNF)-α were positively correlated to phonic tic scores. IL-12 p40 and TNF-α were positively correlated to total tic scores. IL-12 p70 and IL-17a negatively correlated to impairment scores and total YGTSS scores. Tic disorder patients and healthy controls exhibit different cytokine profiles. Only patients with mild symptoms exhibit significant correlations, suggesting that the correlations between cytokine levels and tic symptoms are more relevant during the mild or remission phases. Our results present the importance of IL-1ß and TNF-α, among others, but the identification of key cytokines are still necessary.

[The problem of comorbid disorders in attention deficit hyperactivity disorder in children and adolescents: clinical cases]. / Problema komorbidnykh rasstroistv pri sindrome defitsita vnimaniya s giperaktivnost'yu u detei i podrostkov i ikh korrektsiya: klinicheskie nablyudeniya.

The problem of comorbid disorders in attention deficit hyperactivity disorder (ADHD) is considered, which occur in at least 60% of patients and lead to additional difficulties in intra-family, school and social adaptation. Children and adolescents with ADHD have a wide range of neurological and somatic disorders caused by complex polygenic pathogenetic mechanisms. Among the pathologies associated with ADHD in this cohort of children, neurotic and anxiety manifestations, motor disorders: dyspraxia, discoordination, impaired gross and fine motor skills, tics, behavioral disorders, enuresis, tension cephalgia are common disorders. Treatment of ADHD should be pathogenetic, taking into account the main symptoms of ADHD and manifestations of comorbid disorders, since it is quite long. When choosing pharmacotherapy, it is preferable to use drugs with verified efficacy not only in the correction of ADHD, but also concomitant behavioral, motor and emotional disorders. Also an important aspect in the pediatric clinic is the use of drugs with a reliable safety profile.

Non-just-right experiences are more closely related to OCD than tics in Tourette patients.

Complex tics and obsessive or compulsive behaviour can be difficult to differentiate diagnostically. The majority of adult patients with Tourette syndrome report experiencing premonitory urges before tics. Some of these experiences have been linked to non-just-right experiences (NJRE), which are frequently reported by patients with obsessive-compulsive disorder or behaviours (OCD/OCB). We aimed to assess whether NJRE are more closely related to tics and tic-associated premonitory urges or whether they are more closely associated with OCD. A total of N = 111 patients (mean age = 34.77 + /-12.93; N = 37 female) with a confirmed diagnosis of Tourette syndrome completed the premonitory urges for tic disorders scale (PUTS), the revised non-just-right experiences scale (NJRE-QR), and questionnaires regarding their tic severity, and comorbid OCD/OCB. A multi-trait-multi-methods matrix was calculated to examine associations amongst scales measuring tic-related and OCB-related phenomena. The PUTS correlated overall higher with tic questionnaires than with OCD/OCB questionnaires. The NJRE correlated higher with OCD symptoms than with tic severity. The results indicate that non-just-right experiences are more closely associated with comorbid OCB than with tics in patients with Tourette syndrome.

Neurodevelopmental versus functional tics: A controlled study.

BACKGROUND: An unprecedented increase in newly developed functional tics, mainly in young females, has been reported during the COVID-19 pandemic. We set out to complement existing case series with the largest controlled study to date on the clinical phenomenology of functional tics versus neurodevelopmental tics. METHODS: Data from 166 patients were collected at a specialist clinic for tic disorders during a three-year period overlapping with the COVID-19 pandemic (2020-2023). We compared the clinical features of patients who developed functional tics during the COVID-19 pandemic (N = 83) to patients with Tourette syndrome matched for age and gender (N = 83). RESULTS: Female adolescents and young adults accounted for 86% of the clinical sample of patients with functional tics, who were less likely to report a family history of tic disorders than their matched controls with Tourette syndrome. Co-morbidity profiles were significantly different: anxiety and other functional neurological disorders were more strongly associated with functional tics, whereas attention-deficit and hyperactivity disorder and tic-related obsessive-compulsive behaviors co-occurred more frequently with neurodevelopmental tics. Overall, absence of tic-related obsessive-compulsive behaviors (t = 8.096; p < 0.001) and absence of a family history of tics (t = 5.111; p < 0.001) were the strongest predictors of the diagnosis of functional tics. Compared to neurodevelopmental tics, functional tics were more likely to present acutely/subacutely at a later age (21 versus 7 years), without a clear rostro-caudal progression. Coprophenomena, self-injurious behaviors, and complex clinical manifestations such as blocking tics, throwing tics, and tic attacks, were all over-represented in the functional group. CONCLUSIONS: Our findings provide robust confirmation of both patient-related variables and tic characteristics contributing to the differential diagnosis between functional tics developed during the pandemic and neurodevelopmental tics reported by patients with Tourette syndrome.

Study protocol: A cross-sectional survey of clinicians to identify barriers to clinical practice guideline implementation in the assessment and treatment of persistent tic disorders.

INTRODUCTION: Eight members of the International Parkinson's Disease and Movement Disorders Society Tic and Tourette Syndrome Study Group formed a subcommittee to discuss further barriers to practice guideline implementation. Based on expert opinion and literature review, the consensus was that practice variations continue to be quite broad and that many barriers in different clinical settings might negatively influence the adoption of the American Academy of Neurology and the European Society for the Study of Tourette Syndrome published guidelines. OBJECTIVES: 1) To identify how clinical practices diverge from the existing American Academy of Neurology and European Society for the Study of Tourette Syndrome guidelines, and 2) to identify categories of barriers leading to these clinical care gaps. METHODS AND ANALYSIS: This article presents the methodology of a planned cross-sectional survey amongst healthcare professionals routinely involved in the clinical care of patients with persistent tic disorders, aimed at 1) identifying how practices diverge from the published guidelines; and 2) identifying categories of barriers leading to these clinical care gaps. Purposeful sampling methods are used to identify and recruit critical persistent tic disorders stakeholders. The analysis will use descriptive statistics.

Functional tics: Expanding the phenotypes of functional movement disorders?

BACKGROUND AND PURPOSE: Until the outbreak reported during the COVID-19 pandemic, functional tics were considered to be a relatively rare clinical phenotype, as opposed to other functional movement disorders such as functional tremor and dystonia. To better characterize this phenotype, we compared the demographic and clinical characteristics of patients who developed functional tics during the pandemic and those of patients with other functional movement disorders. METHODS: Data from 110 patients were collected at the same neuropsychiatry centre: 66 consecutive patients who developed functional tics without other functional motor symptoms or neurodevelopmental tics and 44 patients with a mix of functional dystonia, tremor, gait, and myoclonus. RESULTS: Both groups were characterized by female sex preponderance (70%-80%) and (sub)acute onset of functional symptoms (~80%). However, patients with functional tics had a significantly earlier age at onset of functional symptoms (21 vs. 39 years). Exposure to relevant social media content was reported by almost half of the patients with functional tics, but by none of the patients with other functional movement disorders. Comorbidity profiles were similar, with relatively high rates of anxiety/affective symptoms and other functional neurological symptoms (nonepileptic attacks). CONCLUSIONS: Patients who developed functional tics during the pandemic represent a phenotypic variant of the wider group of patients with functional movement disorders, associated with younger age at onset and influenced by pandemic-related factors, including increased exposure to specific social media content. Diagnostic protocols and treatment interventions should be tailored to address the specific features of this newly defined phenotype.

Physiological and introspective antecedents of tics and movements in adults with tic disorders.

OBJECTIVE: To investigate the subjective phenomenon and the neural underpinnings of tics compared with voluntary movements in patients with tic disorders. METHODS: We recorded electroencephalographic and electromyographic data while subjects completed a Libet clock paradigm. Patients and healthy volunteers reported the times of W (willing to move) and M (movement occurrence) while performing voluntary movements. This was repeated only for the patients for the tics. RESULTS: In the patients, W and M times preceding voluntary movements and tics did not significantly differ from voluntary movements of healthy volunteers. The Bereitschaftspotentials in the patients were similar to healthy volunteers. Tics were only assessable for 7 patients due to artifacts. Two subjects did not show Bereitschaftspotentials, and they reported the lowest levels of tic voluntariness. 5 subjects did not show beta band event-related desynchronization before tics. CONCLUSIONS: For patients, the sense of volition for tics is similar to that of their voluntary movements which is similar to normal. Patients showed dissociations between the Bereitschaftspotential and beta desynchronization for tics, with 5/7 showing normal Bereitschaftspotentials and 2/7 showing desynchronization. The absence of desynchronization may suggest attempts to suppress tics. SIGNIFICANCE: This physiology shows a difference for most tics compared with normal movements.

Distinguishing functional from primary tics: a study of expert video assessments.

BACKGROUND: Reliably applied criteria to differentiate functional from primary tics are lacking. In the absence of biological markers, the development of new diagnostic criteria to assist clinicians is predicated on expert judgement and consensus. This study examines the level of diagnostic agreement of experts in tic disorders using video footage and clinical descriptions. METHODS: Using a two-part survey, eight experts in the diagnosis and management of tics were first asked to study 24 case videos of adults with primary tics, functional tics or both and to select a corresponding diagnosis. In the second part of the survey, additional clinical information was provided, and the diagnosis was then reconsidered. Inter-rater agreement was measured using Fleiss' kappa. In both study parts, the factors which influenced diagnostic decision-making and overall diagnostic confidence were reviewed. RESULTS: Based on phenomenology alone, the diagnostic agreement among the expert raters was only fair for the pooled diagnoses (κ=0.21) as well as specifically for functional (κ=0.26) and primary tics (κ=0.24). Additional clinical information increased overall diagnostic agreement to moderate (κ=0.51) for both functional (κ=0.6) and primary tics (κ=0.57). The main factors informing diagnosis were tic semiology, age at tic onset, presence of premonitory urges, tic suppressibility, the temporal latency between tic onset and peak severity, precipitants and tic triggers and changes in the overall phenotypic presentation. CONCLUSIONS: This study confirmed that in the absence of clinical information, the diagnostic distinction between primary and functional tics is often difficult, even for expert clinicians.

Automated Motor Tic Detection: A Machine Learning Approach.

BACKGROUND: Video-based tic detection and scoring is useful to independently and objectively assess tic frequency and severity in patients with Tourette syndrome. In trained raters, interrater reliability is good. However, video ratings are time-consuming and cumbersome, particularly in large-scale studies. Therefore, we developed two machine learning (ML) algorithms for automatic tic detection. OBJECTIVE: The aim of this study was to evaluate the performances of state-of-the-art ML approaches for automatic video-based tic detection in patients with Tourette syndrome. METHODS: We used 64 videos of n = 35 patients with Tourette syndrome. The data of six subjects (15 videos with ratings) were used as a validation set for hyperparameter optimization. For the binary classification task to distinguish between tic and no-tic segments, we established two different supervised learning approaches. First, we manually extracted features based on landmarks, which served as input for a Random Forest classifier (Random Forest). Second, a fully automated deep learning approach was used, where regions of interest in video snippets were input to a convolutional neural network (deep neural network). RESULTS: Tic detection F1 scores (and accuracy) were 82.0% (88.4%) in the Random Forest and 79.5% (88.5%) in the deep neural network approach. CONCLUSIONS: ML algorithms for automatic tic detection based on video recordings are feasible and reliable and could thus become a valuable assessment tool, for example, for objective tic measurements in clinical trials. ML algorithms might also be useful for the differential diagnosis of tics. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

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.

Efficacy of clonidine in the treatment of children with tic disorder co-morbid with attention deficit hyperactivity disorder.

OBJECTIVE: The current research was designed to assess the efficacy of clonidine in the treatment of children with tic disorder co-morbid with attention deficit hyperactivity disorder. PATIENTS AND METHODS: A total of 154 children with tic disorder co-morbid with attention deficit hyperactivity disorder admitted to our hospital from July 2019 to July 2022 were recruited and assigned to receive either methylphenidate hydrochloride plus haloperidol (observation group) or clonidine (experimental group), with 77 cases in each group. Outcome measures included clinical efficacy, Yale Global Tic Severity Scale (YGTSS) scores, Conners Parent Symptom Questionnaire (PSQ) scores, and adverse events. RESULTS: Clonidine was associated with markedly higher clinical efficacy vs. methylphenidate hydrochloride plus haloperidol (p<0.05). Clonidine offered more significant mitigation of the tic disorder vs. methylphenidate hydrochloride plus haloperidol, as evinced by the lower kinetic tic scores, vocal tic scores, and total scores (p<0.05). Children exhibited markedly milder tic symptoms after clonidine monotherapy vs. those with dual therapy of methylphenidate hydrochloride and haloperidol, suggested by the lower scores of character problems, learning problems, psychosomatic disorders, hyperactivity/impulsivity, anxiety index, and hyperactivity index (p<0.05). Clonidine features a higher safety profile than methylphenidate hydrochloride plus haloperidol by reducing the incidence of adverse events (p<0.05). CONCLUSIONS: Clonidine effectively alleviates tic symptoms, reduces attention deficit and hyperactivity/impulsivity in children with tic disorder co-morbid attention deficit hyperactivity disorder, and features a high safety profile.