Other treatments

Increased activity in the left inferior parietal cortex (BA40) appears to be involved in the generation of tics. However, inhibitory repetitive transcranial magnetic stimulation (rTMS) compared to sham and applied to the left prefrontal cortex (BA 40) in 29 adults with TS showed no evidence of benefit on tics \citep{Paulus_2023}.
Two randomized, controlled trials of median nerve stimulation (MNS) for treatment of tics appeared in 2023, following up on the fascinating initial report by Morera Maiquez and colleagues in 2020 \citep{32502412}. The first was an in-laboratory crossover trial comparing repeated 1- or 5-minute sessions of 10 or 12 Hz stimulation in 32 people with a CTD \citep{Iverson_2023}. Rhythmic MNS was given on one day for repeated stimulation-on and -off, 1- and 5-minute blocks, and arrhythmic MNS at the same mean frequency on another day. Either produced significant improvement in tics and premonitory urges, to a similar degree. Since only rhythmic stimulation increases contralateral sensorimotor cortex 12 Hz activity on EEG \citep{32502412} or MEG \citep{Houlgreave2022}, those effects do not reflect the mechanism of the clinical benefit. 
The second MNS controlled trial was a home-based parallel-group study of a wristwatch-style stimulation device \citep{37133932}. The active treatment (N=45) used unilateral 10 Hz MNS at a current just above the threshold for activating movement of the thumb. A sham condition (N=45) was MNS that began at the same current as the active treatment, but current was smoothly decreased by about half over the next minute. Both treatments were given for a total of 10 minutes (5 blocks of 2 min on, 1 min off) every morning for 4 weeks. Both treatments activated sensory nerve fibers, and participants were adequately blinded. A third, wait-list condition (N=45), was meant to measure the magnitude of the placebo response in the sham treatment group. During MNS, active treatment was superior to sham MNS and to wait-list controls, and interestingly, the latter two groups had approximately equal responses. Surprisingly, even though stimulation was only on for 10 minutes a day, clinical response "offline," i.e., YGTSS rated over the entire past week, was also clearly more effective with active MNS.
Willford and Deeb published a scoping review on multidisciplinary care in TS. Thirty one articles were considered. Four primary benefits of multidisciplinary care were identified, making it the preferred model advocated by patients, physicians and organizations to improve clinical outcome. However, limitations to this approach and to this approach and lack of empirical evidence were also highlighted \citep{Willford2023}

Treatment for tic-like functional symptoms

Recent years have seen a considerable increase in patients displaying FTLBs, rather than tics as in TS or CTD. Even though researchers have agreed on how these symptoms may be differentiated from tics \citep{Pringsheim_2023}, little is published on how functional tic-like behaviors may be treated. In an Australian case series published by Maxwell and colleagues \citep{Maxwell2023}, 8 participants (13-20 years) with functional tic-like behaviors received an adapted CBIT intervention. The adaptations included added components from third-wave CBT, with the aim to target both the tic-like symptoms and potential underlying (and triggering) stress. Overall, cases showed large tic severity reductions (YGTSS-TTS) from baseline to post-treatment, indicating preliminary support for the intervention. Larger and controlled studies are warranted.

Tics, family and society

Pring and colleagues reviewed the topic of stigma in TS \citep{38159134}. Evidence from 47 publications showed lower self-esteem in youth TS/CTD, who experienced more frequent bullying and other kinds of peer abuse. The community environment contributed, including school and work settings and the general public.
Knowledge of TS among teachers was assessed in a study by Sapozhnikov and colleagues \citep{Sapozhnikov2023}. Differences in knowledge on TS, self-perceived understanding and use of sources of information were examined in 144 teachers of children with TS and 78 teachers of control subjects, using the pilot questionnaire Teacher Understanding of Tourette Syndrome Survey (TUTS). Teachers of children with TS had higher self-perceived understanding, more knowledge, and used more sources of information compared to the teachers in the control group.
Stacy and colleagues gathered information on perceptions about TS among physicians and caregivers and compared the attitudes between different specialists (neurologists, psychiatrists) and caregivers. While physicians consider pharmacotherapy even when tics are slightly bothersome, caregivers have a preference for behavioral interventions \citep{Stacy2023}.
Fletcher and colleagues evaluated the professional development needs of health care professionals regarding TS \citep{Fletcher2023}. As a result, healthcare workers reported urgent need to have access to evidence-based webinars and materials about TS and OCD. While 80% of participants had patients with TS and/or OCD in their practice, only 50% had any formal training in this area. As part of the TS OCD Alberta Network, a program consisting of twelve online webinars was delivered.  
Diagnostic accuracy in determining tic diagnosis was explored by a group from South Korea \citep{Sung2023}. They found that  in the vast majority of cases (96.5%), diagnoses of different tic disorders were made correctly. 
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 among clinicians treating patients with tics \citep{Martindale2023}. The following barriers were identified: accessibility to specialized care, financial costs or coverage of treatment, neuropsychiatric comorbidities, treatment side effects, and stigma of the disease.  
Marino and colleagues  explored patients' experience of accessing support from primary care physicians in the UK \citep{Marino2023}. Altogether, more negative than positive experiences were reported. Main areas of frustration included lack of exploration of tics or no psychoeducation. Around 20% of participants had problems to get a referral to a specialist. When it comes to specialized care, adults were mainly seen by neurologists, while children mainly were treated by psychiatrists or pediatricians. Only 28% of patients were seen by physicians specialized in tic disorders. The average waiting time for children was 3-6 months but it was much longer for adults. One fifths of people was discharged from the clinic without further support, while 30% reported support by private healthcare.   
 In "‘No ill will’: Ticcing on Moral Grounds" Curtis-Wendlandt, argues that tics are less blameworthy than other intentional actions, but are often misconstrued as morally salient behaviours \citep*{Curtis_Wendlandt_2023}. Bervoets and colleagues published an interesting viewpoint following similar lines of thought and inviting more inclusive patient-based perspective \citep{Bervoets2023}
Coleman and Melia investigated the topic of self-identity in females with TS. The  methodology was a focused semi-structured interview conducted via Zoom \citep{Coleman2023}.   Five themes were established: "I'm not normal", "I just want to be me", I'm a "people pleaser", seeing oneself as an "outsider", and "it's just part of me…it's not going anywhere".  Difficulties with self-acceptance and the autonomy to be one's true self were noted and appeared to be intensified by stereotypical gender roles and attempts to conceal tics. Findings also suggested that personal growth and feelings of mastery can be achieved through embracing TS as part of one's identity, or recognizing it as just one aspect of the self. Psychological support focused on accepting and living with tics rather than reducing them may benefit this population and is currently difficult to access. Consideration should also be given to improving the availability of support groups where women with TS can meet others like themselves.  
An interesting topic of moral decision making in patients with TS was explored by Vicario and colleagues \citep{Vicario2023a}. The authors found higher inclination for utilitarian solutions of moral dilemmas in patients with TS. Of note, TS individuals had more tendency to quantify something as morally wrong or right.  The authors concluded that there might be neurobiological correlates of inappropriate behaviors in people with TS that could be an underlying cause of the higher utilitarian moral decision-making.  
Wellen and colleagues investigated health care experiences among a sample of caregivers of children with tic disorders using a survey \citep{37820348}. They found that the majority (70%) of families first consulted their pediatrician/primary care provider, and caregivers reported receiving care in line with current best practice guidelines. However, caregivers in the current sample also perceived a lack of knowledgeability on the part of their first providers.
The topic of stigma and TS was raised by Shiu and colleagues \citep{Shiu2023a}. The authors identified three types of enacted stigmas: traumatic events, confrontations, and subtle mistreatments. While traumatic events were associated with tic severity, subtle mistreatments contributed to impairment of quality of life.  
Lund and colleagues investigated the impact of TS on education \citep{Lund2023}. This was a longitudinal study to assess the educational achievements at different timepoints.  Overall, children with TS had a lower passing rate at lower secondary school and high school compared to healthy controls. These disparities were more likely driven by the severity of comorbidities than tic severity.