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### Tic suppression  Since tic suppression is part of the treatment protocol for the Comprehensive Behavioral Intervention for Tics (CBIT) and Exposure and Response Prevention, there has been increased interest in investigating the characteristics of tic suppression and the factors that affect it. A study of 26 TS adolescents compared free ticcing with a tic suppression condition \citep{25786675}. During the free ticcing condition condition,  tic distribution across body locations was consistent with the general view that most tics occur at the level of the shoulders and above. Eye above: eye  tics were the most frequent frequent,  followed by facial/cervical tics. Limb tics tics,  and tics involving the trunk were the least common. During the tic suppression condition,an increase in  eye tics were seen increased  in 10 subjects along with an increase in subjects, as did  hand tics in 3 subjects. Tic suppression was most successful when it involved suppression of for  tics inthe  body locations that are generally involved in with  fewer tics (such tics, such  as the legs and the trunk). trunk.  The authors suggest that tic suppression involves specific, rather than global, inhibition since some types of tics are easier to suppress than others. Historically Historically,  different categories have been used to classify tics tics,  such as simple vs. complex tics and motor vs. phonic tics. The results of this study suggest that future research clarifying the nature of the tics associated with particular may benefit from including  body locations location  in even more detail (e.g., whether premonitory urges are more likely to be associated with tics in particular body locations) may be productive. analysis of tics.  By definition, children with Tourette syndrome (TS) have had tics for over a year. They can often suppress their tics briefly and they do so more effectively when rewarded for successful suppression. It has not been known whether the ability to suppress tics develops only with practice over the years of having tics or whether the ability to suppress tics is present when tics initially occur. \citep{Greene_2015_NTsuppress} \citet{Greene_2015_NTsuppress}  addressed this question in children whose tics had developed within the past few months. When children received tokens with monetary value for tic-free intervals, they had significantly more of these intervals compared to a baseline, unrewarded condition. This result suggests the possibility that behavior therapy for tics may work, at least for some children, even before TS can be diagnosed. ### Sensory phenomena   In the last few years research has focused on the role of premonitory urges in TS since these urges are generally triggers for tics and are as bothersome as the tics themselves to many people. Premonitory urges have a sensory component and many TS patients also report sensory sensitivities. Researchers have been clarifying the nature of premonitory urges and attempting to determine the underlying causes of the sensory sensitivities.  Scores on the Premonitory Urge for Tics Scale (PUTS) and the University of São Paulo Sensory Phenomena Scale (USP-SPS) were significantly correlated with total tic severity, tic complexity and vocal tic scores for TS in  adults with TS  \citep{Kano_2015}. The PUTS and USP-SPS scores were also correlated with scores on the Dimensional Yale-Brown Obsessive-Compulsive Scale. This study provides additional evidence that the association between premonitory urges, as measured by PUTS scores, urges  and tics is complex and may be influenced by obsessive-compulsive tendencies. Another study examined the association between premonitory urges and interoceptive awareness \citep{25879819}. Interoceptive awareness was measured by how well subjects were able to mentally track their heartbeats, without being able to take their own pulse, during a specific period of time. Interoceptive awareness, tic severity, and obsessive-compulsive symptom severity were used in a multiple regression to predict PUTS scores. Greater interoceptive awareness and tic severity were significantly associated with higher PUTS scores. OCD symptom severity was not significantly  associated with PUTS scores. The authors suggest that high interoceptive awareness might result in may lead  people setting to set  a low threshold for perception of their own internal physiological sensations and therefore interpreting these sensations as an urge to tic. Interestingly, TS subjects hada  lower interoceptive awareness than the controls and suggested controls, suggesting  that this downregulation of interoception might instead  reflect a compensatory process. ### Symptoms and comorbidity  Recent research has again demonstrated the wide prevalence of TS-associated comorbities and is a reminder of the need to perform studies with large enough sample sizes to examine the effects of comorbidities on the dependent variables of interest.  A retrospective review of 1,000,000 people in the Taiwan National Health Insurance Research Database examined the association between epilepsy and TS \citep{26597416}. 1062 1,062  children and adolescents with TS were matched on age and sex with a control group of 3186. The TS group had an 18-fold increased risk of epilepsy compared to the control group and, even group; the risk was still elevated at 16-fold  after adjusting for comorbidities (i.e., bipolar disorder, depression, learning difficulties, autism, anxiety disorder, sleep disorder), the risk of epilepsy was still 16-fold. Although the disorder). The  authors raise acknowledge  the issue possibility  that some tics may have been mistaken for seizures, they also suggest that clinicians follow TS children closely since they are at-risk for given  the development nature  of epilepsy. the data set, but these data do suggest an important hypothesis for future confirmation.  In a large study of psychiatric comorbidity in TS, approximately 800 families were recruited primarily from TS specialty clinics in four different countries over a 16-year period \citep{25671412}. A total of 1374 participants with TS and 1142 family members unaffected by TS were included. 86% of the TS participants had at least one psychiatric comorbidity and 72% had either OCD or ADHD. Other disorders, involving mood, anxiety or disruptive behavior, each occurred in approximately 30% of the TS participants. The genetic correlations between TS and mood were accounted for by ADHD and OCD, while ADHD alone accounted for the genetic correlations of TS with anxiety and disruptive behavior disorders. See also \citep*{Prime:Hirschtritt:2015}.  A study of 400 patients seen at a TS specialty clinic found that 39% had coprolalia and 20% had copropraxia \citep{26089672}. When the 222 patients with full comorbidity data were examined, only 13.5% had "pure" TS (i.e., without comorbidities). None of the "pure" TS group had coprolalia and none had a family history of obsessive-compulsive disorder. In contrast, 39% of the group with comorbidities exhibited coprolalia. These findings support results are consistent with  previous findings thatpeople with "pure" TS are substantially different from those who have  comorbid conditions are very important  in addition to TS. clinical care and research on tic disorders.  Emotional regulation difficulties were described in three studies reminding us that TS patients often report that tics are the least of their problems. An experienced clinician, clinician  who has done research on "rage attacks" in TS, TS  has provided a clinically useful summary of current knowledge regarding aggressive symptoms in TS, OCD, ADHD and mood disorders disorders,  and described treatment options \citep{Budman_2015}. In another study, greater irritability was seen in TS adults with more severe tics and those with comorbid ADHD \citep{25716486}. \citet{26144583} found that both male and female TS subjects had significantly higher scores for personal distress and rated their abilities to take other people's perspectives lower than the control subjects did. Given that emotional regulation difficulties are frequently associated with greater tic severity, improving emotional modulation skills may also be an appropriate target of psychological interventions. More research is also being conducted on personality differences associated with TS. A small study of 17 male adolescents \citep{26078419} found that the only significant  difference between the TS subjects and 51 age- and gender-matched controls on the Minnesota Multiphasic Personality Inventory-Adolescent was that the TS subjects scoredsignificantly  higher on the Obsessiveness Content Scale. In contrast contrast,  a study of 50 TS adults in Germany used a variety of instruments to measure psychological symptoms and personality traits \citep{26112450}. Comorbidities were common with 41% having OCD, 28% being depressed and 26% having ADHD. Patients with OCD had more severe tics and there was a trend for those with ADHD to have more severe tics. Only 29% of the patients had no pathological personality traits. The demand-anxious trait was the most common personality trait (measured with the Inventory of Clinical Personality Accentuations) seen in patients and was present in 39% while histrionic personality traits were not found in any of these patients. Personality traits in patients with "pure" TS were comparable to those of the control group. Interestingly, ADHD did not contribute to increased probability of pathological personality traits. Although quality of life was affected by both personality traits and comorbidities, personality traits had a larger impact on quality of life. The results of these two studies support previous research that substantial differences exist between TS children and adults in terms of the comorbidities that they exhibit. ### Course  More research is being conducted that follows the developmental progression of TS and its comorbidities. This work may provide clues that help clarify what factors contribute the appearance and disappearance of transient tics and what factors contribute to the developmental decline in tic severity with the result that most TS adults have only mild, if any, tics.  Baby videos were used in a study in Italy of 34 children who were identified as having autistic behaviors in their second year of life \citep{26246137}. Families reported that development during the first year of life had been normal and they donated videos that had been recorded before these children were 6 months old. Videos of 18 boys were examined in detail. Abnormal general movements, which are spontaneously generated by central pattern generators and modulated by more rostral brain regions, were seen in 10 of the 11 boys who were eventually diagnosed with autism spectrum disorder. In contrast, normal general movements were seen in the 8 boys who had some  autistic features and 7 of these boys were later diagnosed with Tourette syndrome. 4 of the boys who were eventually diagnosed with autism spectrum disorder had TS as a comorbidity. These results, combined with the recent nearly ubiquitous availability of home baby videos in some cultures, suggest that a similar  pseudo-prospective study design could be used to identify features predicting later development of TS. The clinical characteristics of children who developed TS before the age of 4 were compared with those who were older than 6 at tic onset \citep{26596364}. The younger group had a higher rate of stuttering, other speech dysfluencies (e.g., speech initiation difficulties, speech prolongation), and oppositional defiant disorder. There was no difference between the two groups in rate of ADHD or obsessive-compulsive symptoms. Interestingly, the early-onset group was more likely to have a mother with tics. The authors suggested a number of possible explanations. These hypotheses include the idea that this difference in onset age might be related to mother sensitivity to the child's symptoms resulting in tics being diagnosed at a younger age or possible prenatal or perinatal environmental factors. An alternative explanation may be related to TS being much less common in girls than in boys. Consequently, tics in a woman may represent a higher genetic load with this higher genetic load resulting in a more severe form of tics and an earlier age of onset.   Another study of Researchers re-evaluated  75 TS patients previously seen at a University-based clinic provided clinic, with  a mean  follow-up period that averaged of  9 years \citep{25193042}. This study found that reported TS impairment was more likely to decrease over time in males and increase in females. In addition, women were more likely than men to have more tics in adulthood in various  body regions, primarily the upper extremities, affected by tics in adulthood. extremities.  This result suggests that gender continues to influence TS symptoms beyond adolescence.