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## Treatment  Traditionally, the therapeutic interventions chosen to treat a particular individual have varied depending on a variety of factors including tic severity, treatment history, age and degree of impairment related to the tics. For mild tics in young children, clinicians generally provide reassurance. Medication is provided for many patients especially if they have comorbidities or have bothersome tics. Although psychotherapeutic interventions can be useful, finding a trained clinician can be difficult. DBS treatment is reserved for patients who have tics that are causing a significant impairment in functioning and have not been successfully treated with other therapeutic interventions.\citet*{Jankovic_2015} provided an overview of tic treatments.  ### Psychotherapy 
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A small, uncontrolled open trial of mindfulness-based stress reduction treatment was provided to 18 individuals who were at least 16 years old \citep{25149879}. Treatment consisted of eight weekly two-hour group classes and one four hour retreat. Participants were taught a tic-specific meditation exercise that involved noticing any urges to tic while maintaining a focus on one's breathing rather than trying to change or eliminate the urge to tic. Only one subject dropped out and overall tic severity was decreased by 20% for participants who completed the program. An independent evaluator rated ten subjects as much improved" or "very much improved" and these subjects were considered treatment responders. The gains for the fifteen participants, who had not had medication changes, were maintained at a one month follow-up visit suggesting that improvements reflected more than just the waxing and waning pattern commonly associated with tic severity.  An open-label trial of psychotherapy using a cognitive psychophysiological model of tic behavior was conducted with 102 adults who had TS or chronic tic disorder \citep{26250742}. Ten weeks of individual psychotherapy involved a number of components including increasing tic awareness; improving muscle control; preventing excessive muscle tension; decreasing an overactive action style; identifying low and high risk activities in terms of tic probability and probability;  highlightingthe  differences in behaviors, thoughts and feelings related to differences in tic probability; decreasing perfectionistic beliefs linked to tension; generalization;  and relapse prevention. These psychotherapy components were chosen becauseof  prior research suggesting suggested  that some patients people  with tics have perfectionist beliefs when they plan actions and this leads leading  to an impulsive "impulsive  overactive style resulting in frustration, tension style" that produces frustration  and tension in addition to  tics. Large effect sizes were seen for both patient group compared to the waiting list control group: 65% of the chronic tic disorder group and 74% of the TS group had reductions of more than 35% on the Tourette Syndrome Global Scale. YGTSS Total scores were also sigificantly significantly  decreased for both patient groups. At the end of treatment 78 of 85 completers were rated as having no more than mild symptoms, regardless of the starting severity, while the other 7 were considered to have moderate symptoms. Large effect sizes were seen whether tics were simple or for tic subtypes (i.e., simple,  complex, motor, phonic)  and similar results were seen for various tic locations (eyes, face, head, neck and shoulder, trunk and abdomen, or phonic). abdomen).The TSGS improvements were maintained in the 52 subjects who completed a 6 month follow-up evaluation.  \citet{26022060} examined the effects of this psychotherapy approach on event-related potentials and lateralized readiness potentials (LRPs). EEGs were recorded for 20 TS subjects and 20 control subjects subjects,  matched for age, sex and intelligence, while performing a stimulus-response compatibility inhibition task. During the No-Go condition, the TS group exhibited a delayed and overactivated frontal late positive component. component on the NoGo portion of the task.  The authors interpreted this result as evidence that considered  this frontal activation may be as evidence of  an adaptive mechanism that allows allowed  patients to perform similarly to the control subjects in terms on the task. This difference did not normalize as a result  of their behavioral performances. psychotherapy and this is consistent with the view that the frontal overactivation is adaptive.  TS subjects exhibited delayed a larger incorrect activation of the  stimulus-locked LRP (sLRP) onset. TS subjects also displayed in addition to  largerresponse-locked LRP (rLRP) peak amplitudes, which are associated with the execution of the motor program for the  correct response. The authors suggest that the larger amplitudes may reflect overactivation activation  of the premotor sLRP  and motor cortex in TS patients. delayed correct activation sLRP onset.  Although sLRP onset and rLRP peak normalized after psychotherapy, the larger sLRP amplitude did not.Given the high rate of OCD comorbidity among TS patients, it is encouraging that more research is examining similarities and differences between OCD patients with and without tics. Tic status was evaluated using the YGTSS in a psychotherapeutic study of 124 children and adolescents with OCD who had shown a partial response to a serotonin reuptake inhibitor \citep{26126872}. Tics were identified in 53% of the study participants, but these subjects did not differ significantly from tic-free participants in terms of age, sex, family history, or OCD impairment or severity.  The high rate of tics in this sample is partially explained by the inclusion of subjects with tics for less than one year. Cognitive-behavioral therapy resulted in similar OCD symptom improvement in both groups. In another study, 12 children and adolescents with tics whose OCD symptoms had not improved after 14 weeks of cognitive-behavioral authors suggest that  therapy received either 16 weeks of sertraline treatment or 10 additional sessions produced some normalization  of CBT \citep{26091197}. Externalizing disorders were more common in the tic patients (50%) than activation  in the non-tic patients (5.3%), while internalizing disorders were more common pre-motor and motor cortex  in the non-tic TS  patients.The tic patients showed more improvement when switched to sertraline rather than additional CBT, while the non-tic patients showed similar improvement with either treatment. The authors suggested that the dopaminergic action of sertraline might have helped the OCD patients with tics; alternatively one might conclude simply that pediatric OCD patients with tics respond differently to treatment than do those without tics.  ### Medication  Efforts to maximize the value of pharmacological treatment continue. One of our colleagues highly recommended the following review of current medication treatment practice in Germany: \citep{24888751}. These researchers examined psychotropic prescriptions issued in Germany between 2006-2011 for children and adolescents who had been diagnosed with a tic disorder. There was only a slight increase in the number of prescriptions overall issued in 2011 compared to 2006. The mostly frequently prescribed medications were ADHD medications. Antipsychotics were the next most frequently prescribed; second-generation antipsychotics were more frequently prescribed over this time period, with a relative increase in risperidone prescriptions specifically. Patients with a TS diagnosis were more likely to receive psychotropic medication than were children with other tic diagnoses.  \citet{26002052} reported on  a carefully designed, thoughtful pilot study of glutamatergic modulators as tic treatment. Twenty-three children with TS completed a double-blind, parallel group study involving 6 weeks of placebo, D-serine (up to 30 mg/kg/day), or riluzole (up to 200 mg/day). Total tic scores from the YGTSS improved by 25-38% in each group, without significant group differences. Although power was limited by the small sample size, this null result argues against eager pursuit of glutamatergic medications for TS at this juncture. A meta-analysis of 22 randomized, controlled trials (RCTs) involving 2,385 children with ADHD found no causal relationship between stimulants and onset of tics \citep{26299294}. Rather, tics were associated with ADHD itself (5.7% in the psychostimulant groups and 6.5% in the placebo groups). This summary of previous evidence hopefully can further reassure patients and prescribers that stimulants do not cause tics. The evidence for this conclusion is strongest for methylphenidate (19 of the 22 trials), and in a large RCT in children with TS and ADHD, tics _improved_ significantly with methylphenidate \citep{11865128}. In this meta-analysis, results were similar for the 3 trials involving amphetamines, but tic severity did increase in 12 adults with TS after a single intravenous dose of 0.3mg/kg D-amphetamine \citep{23876376}.