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A small, uncontrolled open trial of mindfulness-based stress reduction was provided to 18 individuals who were at least 16 years old \citep{25149879}. Treatment consisted of 8 weekly 2-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 the participants who completed the program. Ten subjects were rated as "much improved" or "very much improved" and thus considered treatment responders. The gains for the treatment responders 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 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 variety of components including increasing awareness of tics, muscle discrimination, decreasing muscle tension and an overactive style of action, identifying low and high risk activities in terms of tic probability, highlighting the differences in behaviors, thoughts and feelings; decreasing perfectionistic beliefs linked to tension and relapse prevention. These psychotherapy components were chosen because of research suggesting that some TS subjects have perfectionist beliefs when they plan actions and this leads to an impulsive overactive style resulting in frustration, tension and tics. Large effect sizes were seen for both treatment groups (TS, CTD) compared to the waiting list controls. 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. 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 complex, and similar results were seen for various tic locations (i.e., eyes, face, head, neck and shoulder, trunk and abdomen; phonic). \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 matched for age, sex and intelligence, while performing a stimulus-response compatibility inhibition task. During the NoGo condition, the TS group exhibited a delayed and overactivated frontal late positive component. The authors interpreted this result as evidence that this frontal activation may be an adaptive mechanism that allows patients to perform similarly to the control subjects in terms of their behavioral performances. TS subjects exhibited delayed stimulus-locked LRP (sLRP) onset. TS subjects also displayed larger response-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 of the premotor and motor cortex in TS patients. Although sLRP onset and rLRP peak normalized after psychotherapy, the larger sLRP amplitude was not.   Psychotherapy Tic status  was provided for evaluated using the YGTSS in a psychotherapeutic study of  124 children and adolescents who had with  OCD and who  had shown a partial response to a serotonin reuptake inhibitor \citep{26126872}.Tic status was evaluated using the YGTSS.  Tics were identified in 53% of the study participants. There were no significant differences participants, but they did not differ significantly  from non-tic participants in terms of age, six, family history, or OCD impairment or severity. Cognitive-behavioral therapy resulted in similar OCD symptom improvement in both groups. The high rate of tics in this sample was is  partially explained by the inclusion of tic disorders subjects  with duration tics for  less than one year. In another study \citep{26091197} \citep{26091197},  12 children and adolescents who had with  tics and were rated as non-responders whose OCD symptoms had not improved  after 14 weeks of cognitive-behavioral therapyeither  received either  16 weeks of sertraline treatment or 10 additional sessions of CBT. Internalizing disorders were more common in the non-tic patients, and while  externalizing disorders were more common in the tic patients (50%) than in the non-tic patients (5.3%). The tic patients showed more improvement when switched to sertraline rather than additional CBT, while the non-tic patients showed similar improvement whether they received sertraline or additional CBT. 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. | **Title** | **Comment** |  |:----------|:------------|  |Biofeedback \citep{25616186} | This A  review discusses the possible relevance of neurofeedback for the treatment of Tourette syndrome and suggests that it may be most useful to treat TS children and adults who also have ADHD. | ADHD \citep{25616186}.  ### Medication  Efforts to maximize the value of pharmacological treatment continues. One of our colleagues highly recommended this 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, with second generation antipsychotics being more frequently prescribed over this time period along with a relative increase in risperidone prescriptions over the same period of time. Tic disorder patients with a TS diagnosis were the group most likely to receive psychotropic medication. | **Title** | **Comment** |  |:----------|:------------|  |Is medication a tic trigger? \cite{26299294} | A meta-analysis of 22 studies involving 2,385 children found no causal relationship between stimulants and tic onset although tics were associated with ADHD itself (5.7% in the psychostimulant groups and 6.5% in the placebo groups). |   |  | [Vigabatrin RCT](http://ir.catalystpharma.com/releasedetail.cfm?ReleaseID=919254) | groups) \cite{26299294}. This summary of previous evidence hopefully can further reassure patients and prescribers that methylphenidate products do not cause tics.  Four patients with treatment-refractory TS were studied in this [this  early report report](http://ir.catalystpharma.com/releasedetail.cfm?ReleaseID=919254)  of results using medication from the GABA-aminotransferase inhibitor class. One patient had a clinically significant reduction in tics while two others had tic reduction of approximately 25% but did not report subjective clinical improvement.|  ### Neurosurgery  Now that deep brain stimulation (DBS) is being used more frequently there have been efforts to standardize clinical treatment protocols in terms of patient selection and to standardize studies on effectiveness and efficacy. A revised consensus statement on DBS in TS appeared recently \citep{25476818}. It provides an important update to the 2006 recommendations \citep{16991144}, guided by almost a decade of generally positive results from an increasingly varied set of patients, though with limited evidence from randomized allocation treatment studies. Several major changes were made in the recommendations. First, the recommendation that DBS patients be 25 years or older has been replaced by a focus on clinical symptoms and severity, rather than a strict age criterion. It was recommended that, severity. However,  at a minimum,a  local ethics committee be involved in evaluations involvement was recommended  for patientswho are  under 18 years of age. The second major modification in the guidelines was that a patient have a caregiver who would be available to accompany the patient to frequent follow-up appointments. In addition, the group recommended absence of active suicidal or homicidal ideation for 6 months prior to surgery. The final change in the guidelines was the importance of identifying and addressingissues related to  personality disorders, malingering, factitious symptoms, embellishment, and other factors that may can  substantially complicate assessment or treatment.Since this form of treatment is becoming more widely available, these recommendations may enable clinicians provide treatment to the patients most likely to benefit.  Fourteen patients were randomly allocated to DBS on-stimulation or off-stimulation conditions for the first 3 months after GPi DBS surgery, followed by a switch to the other condition for another 3 months \citep{25882029}. This was followed by open-label Ratings were collected blind to  stimulation adjustments for both groups. status.  A total of 13 patients completed assessments in both blinded periods. This was followed by open-label stimulation adjustments for both groups.  Total YGTSS scores were 15% lower at the end of the on-stimulation period compared with the off-stimulation period (p=0.048). Three serious adverse events occurred (two infections in the DBS hardware and one episode of hypomania during the blinded on-stimulation condition). This study is praiseworthy because of the on *vs* off stimulation stimulation, randomized,  controlled design. The A case study raised the  issue of temporary DBS treatmentwas raised by a case study  \citep{26290773}. The patient started having simple motor tics at the age of 7 followed by vocal and complex motor tics two years later. The patient also had ADHD and learning difficulties. Thalamic DBS surgery was provided when he developed continuous motor and vocal tics that resulted in his leaving school at the age of 17. A year after surgery his YGTSS score had decreased by 58%. Three years after the surgery the tic severity increased and the IPG was replaced, again followed by improved tic severity. When the patient was 23 it was noticed that the IPG was not operational, yet there had not been any increase in the patient's symptoms. After the device was left off for 2 years and the patient remained stable clinically, the decision was made to remove the device and the patient was still stable 8 months later. This case raises important questions discussed in the consensus statement \citep{25476818}, but without adequate controls, it is impossible to know whether DBS was the cause of tic improvement.  \citet{26180116} reviewed electrophysiological data obtained in nonhuman primate models of TS and in Parkinson disease, with the hope of identifying possible mechanisms to account for the efficacy of high-frequency GPi-DBS in both a hyper- and a hypokinetic movement disorder. This article focuses on the possibility that excessive synchrony and pathological low-frequency oscillations (LFO) impair activation in the motor regions that receive input from the basal ganglia. There is also some evidence that synchronous oscillatory activity and excess LFO contribute to TS. DBS effectiveness is considered to occur because population-scale firing rates are maintained allowing proper encoding of desired movement. When used with Parkinson patients, DBS suppresses excess LFO in the GPE in addition to the GPI. GPI-DBS is theorized to suppress the phasic activations in the GPe and phasic inhibitions in the GPi for TS patients. It is hypothesized that in both medical conditions aberrant output is minimized while the population-averaged firing rate is maintained.   \citet{25882028} discuss various obstacles to carrying out randomized, blinded studies of DBS with appropriate controls.  | **Title** | **Comment** |  |:----------|:------------|  |TMS \citep{25342253} | Deep TMS add-on for intractable TS |  |  |DBS challenges \citep{25882028} | The various obstacles to creating randomized, blinded studies of DBS with appropriate controls for a variety of factors are described briefly.|  ### Other treatment  An open label trial of cranial electrical stimulation (CES) treatment was provided to 42 children with TS who were less than 12 years old \citep{25546850}. The patients applied electrodes to their earlobes when they went to bed so that they could receive the treatment on a daily basis for 24 weeks. Treatment was provided for 60 minutes and they could go to sleep if they wanted. Only one child dropped out before the completion of the study. The mean YGTSS score significantly decreased from 26.3 when they were initially seen to 11.4 after 24 weeks of treatment. fMRI scanning was optional and only 8 subjects completed the scans before and after treatment. Independent component analysis with hierarchical partner matching was used to examine functional connectivity among regions within the cortico-striato-thalamo-cortical circuit followed by Granger causality to examine effective connectivity. After the CES treatment this subsample had stronger functional activity and connectivity in the anterior cingulate cortex, caudate and posterior cingulate cortex and weker activity in the supplementary motor area. These results must be viewed as preliminary, since an RCT is required to rule out spontaneous improvement.  A study finding reporting  a surprisingly strong association between tics and epilepsy was discussed in the "Symptoms and comorbidity" section above  \citep{26597416}. The possible role of autonomic dysfunction in both epilepsy and Tourette Syndrome was discussed in detail, along with a summary of attempts to use electrodermal activity (EDA) biofeedback to treat both conditions. EDA biofeedback, which consisted of 12 sessions over 4 weeks, produced at least a 50% reduction in seizures in more than half of the epileptic subjects and also produced changes in Contingent Negative Variation, which is modulated by changes in peripheral autonomic activity. Based on seizure diaries that were kept by a subset of the patients, these improvements were maintained over a period of years. These results were replicated in a 2014 study by another research group. In contrast, when a similar EDA biofeedback protocol was used with TS subjects \cite{24674962}, TS patients in the active and sham biofeedback groups were not able to reduce their sympathetic activity. Despite this, both the active-beiofeedback active-biofeedback  and sham-control groups had significant decreases in tic frequency and obsessive-compulsive disorder symptoms, and plus  improvements in quality of life related to OCD symptoms.