Implementation and Evaluation of Therapeutic Online Coaching Using Habit Reversal Training in Children With Tourette’s Disorder – A Pilot Study

Cognitive-behavioral interventions can be difficult to implement in daily routine, which is often essential for generalizing treatment effects to natural settings. Furthermore, there is a lack of adequate care options concerning habit reversal training for children with Tourette’s disorder. The objective of this study is to evaluate therapeutic online coaching via videoconferencing in the natural environment of children with Tourette’s disorder in addition to face-to-face therapy (blended therapy). Online coaching took place twice a week for a maximum of 12 weeks. In a single-case study (n = 5; patients aged 8–11 years), the first results were obtained for exploratory purposes, especially with regard to the feasibility and reduction of symptoms and impairment. Various outcome measures were assessed (severity of symptoms, impairment, practical implementation, and satisfaction). Despite some principal limitations, the findings provide first hints that blended therapy is feasible and improves symptoms in some children with tics.Clinical Trial Registration: [https://clinicaltrials.gov/], identifier [DRKS00017199].

Astrocytic ApoE underlies maturation of hippocampal neurons and cognitive recovery after traumatic brain injury in mice

Polymorphisms in the apolipoprotein E (ApoE) gene confer a major genetic risk for the development of late-onset Alzheimer’s disease (AD) and are predictive of outcome following traumatic brain injury (TBI). Alterations in adult hippocampal neurogenesis have long been associated with both the development of AD and recovery following TBI and ApoE is known to play a role in this process. In order to determine how ApoE might influence hippocampal injury-induced neurogenesis, we generated a conditional knockout system whereby functional ApoE from astrocytes was ablated prior to injury. While successfully ablating ApoE just prior to TBI in mice, we observed an attenuation in the development of the spines in the newborn neurons. Intriguingly, animals with a double-hit, i.e. injury and ApoE conditionally inactivated in astrocytes, demonstrated the most pronounced impairments in the hippocampal-dependent Morris water maze test, failing to exhibit spatial memory after both acquisition and reversal training trials. In comparison, conditional knockout mice without injury displayed impairments but only in the reversal phase of the test, suggesting accumulative effects of astrocytic ApoE deficiency and traumatic brain injury on AD-like phenotypes. Together, these findings demonstrate that astrocytic ApoE is required for functional injury-induced neurogenesis following traumatic brain injury.

Trichotillomania: What Do We Know So Far?

Trichotillomania is defined as an obsessive-compulsive or related disorder in which patients recurrently pull out hair from any region of their body. The disease affects mainly female patients, who often deny the habit, and it usually presents with a bizarre pattern nonscarring patchy alopecia with short hair and a negative pull test. Trichoscopy can reveal the abnormalities resulting from the stretching and fracture of hair shafts, and biopsy can be necessary if the patient or parents have difficulties in accepting the self-inflicted nature of a trichotillomania diagnosis. Trichotillomania requires a comprehensive treatment plan and interdisciplinary approach. Physicians should always have a nonjudgmental, empathic, and inviting attitude toward the patient. Behavioral therapy has been used with success in the treatment of trichotillomania, but not all patients are willing or able to comply with this treatment strategy. Pharmacotherapy can be necessary, especially in adolescents and adult patients. Options include tricyclic antidepressants, selective serotonin reuptake inhibitors, and glutamate-modulating agents. Glutamate-modulating agents such as N-acetylcysteine are a good first-line option due to significant benefits and low risk of side effects. Physicians must emphasize that the role of psychiatry-dermatology liaison is extremely necessary with concurrent support services for the patient and parents, in case of pediatric patients. In pediatric cases, parents should be advised and thoroughly educated that negative feedback and punishment for hair pulling are not going to produce positive results. Social support is a significant pillar to successful habit reversal training; therefore, physicians must convey the importance of familial support to achieving remission. This is a review article that aims to discuss the literature on trichotillomania, addressing etiology, historical aspects, clinical and trichoscopic features, main variants, differential diagnosis, diagnostic clues, and psychological and pharmacological management.

Hair-Pulling Disorder

Trichotillomania (TTM) is characterized by the recurrent pulling of one’s hair, resulting in hair loss and significant distress or impairment. Traditional treatment has several limitations that may lead to non-response or relapse. Recent advances that aim to improve treatment include addressing the individual’s pulling patterns, negative or uncomfortable inner experiences that instigate and maintain pulling, or contextual variables that impact pulling. This chapter discusses theoretical models of TTM and developments in behavioral and pharmacological treatments. Habit reversal training (alone and enhanced with dialectical behavior therapy or acceptance and commitment therapy), the comprehensive behavioral model, and web-based treatment are evaluated. Pharmaceutical treatment options, including selective serotonin reuptake inhibitors, antipsychotics, naltrexone, and N-acetylcysteine, are discussed as methods of augmenting behavioral treatment. While considerable advancement has been made in recent years acknowledging the broad range of clinical features associated with TTM, future research must employ rigorous methods to investigate the outcomes of behavioral and pharmacological interventions across the complex patterns among hair pullers.

European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part II: psychological interventions

Part II of the European clinical guidelines for Tourette syndrome and other tic disorders (ECAP journal, 2011) provides updated information and recommendations for psychological interventions for individuals with tic disorders, created by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain original studies of psychological interventions for tic disorders, published since the initial European clinical guidelines were issued. Relevant studies were identified using computerized searches of the MEDLINE and PsycINFO databases for the years 2011–2019 and a manual search for the years 2019–2021. Based on clinical consensus, psychoeducation is recommended as an initial intervention regardless of symptom severity. According to a systematic literature search, most evidence was found for Habit Reversal Training (HRT), primarily the expanded package Comprehensive Behavioral Intervention for Tics (CBIT). Evidence was also found for Exposure and Response Prevention (ERP), but to a lesser degree of certainty than HRT/CBIT due to fewer studies. Currently, cognitive interventions and third-wave interventions are not recommended as stand-alone treatments for tic disorders. Several novel treatment delivery formats are currently being evaluated, of which videoconference delivery of HRT/CBIT has the most evidence to date. To summarize, when psychoeducation alone is insufficient, both HRT/CBIT and ERP are recommended as first-line interventions for tic disorders. As part of the development of the clinical guidelines, a survey is reported from ESSTS members and other tic disorder experts on preference, use and availability of psychological interventions for tic disorders.

Novel measures of Morris water maze performance that use vector field maps to assess accuracy, uncertainty, and intention of navigational searches

Most commonly used behavioural measures for testing learning and memory in the Morris water maze (MWM) involve comparisons of an animal s residence time in different quadrants of the pool. Such measures are limited in their ability to test different aspects of the animal s performance. Here, we describe novel measures of performance in the MWM that use vector fields to capture the motion of mice as well as their search pattern in the maze. Using these vector fields, we develop quantitative measures of performance that are intuitive and more sensitive than classical measures. First, we describe search patterns in terms of vector field properties and use these properties to define three metrics of spatial memory namely Spatial Accuracy, Uncertainty and, Intensity of Search. We demonstrate the usefulness of these measures using four different data sets including comparisons between different strains of mice, an analysis of two mouse models of Noonan syndrome (Ptpn11 D61G and Ptpn11 N308D/+), and a study of goal reversal training. Importantly, besides highlighting novel aspects of performance in this widely used spatial task, our measures were able to uncover previously undetected differences, including in an animal model of Noonan syndrome, which we rescued with the mitogen activated protein kinase kinase (MEK) inhibitor SL327. Thus, our results show that our approach breaks down performance in the Morris water maze into sensitive measurable independent components that highlight differences in spatial learning and memory in the MWM that were undetected by conventional measures.

Tourette and Trichotillomania

This chapter explores the treatment of trichotillomania (TTM; also referred to as hair pulling disorder) and Tourette disorder (TD). TTM and TD exist in separate diagnostic categories but exhibit functional similarities and respond to similar treatments. The chapter reviews the characteristics of each disorder. It then describes habit reversal training (HRT) and function-based interventions, which serve as core therapeutic elements in the treatment of both TTM and TD. The chapter also discusses additional treatment strategies that occur as part of standard protocols for both disorders, before looking at the treatment efficacy research. It considers the key features of the manual-based treatments (behavior therapy protocols), as well as ways these protocols can be flexibly implemented for those with TTM and TD. Finally, consistent with the call for “flexibility within fidelity,” the chapter provides an example of a flexible implementation of these treatments.

A Head-to-Head Comparison of Three Self-Help Techniques to Reduce Body-Focused Repetitive Behaviors

Body-focused repetitive behaviors (BFRBs) include skin picking, trichotillomania, nail biting and cavitadaxia/lip-cheek biting, among other behaviors. For the first time, we compared three different self-help techniques aimed at reducing BFRBs. We explored the acceptance and preliminary efficacy of the approaches and whether the techniques exerted differential effects depending on BFRB-type. A total of 113 participants with at least one BFRB were randomly allocated to either habit reversal training (HRT; active elements: awareness and competing response training), decoupling (DC) or decoupling in sensu (DC-is). Reassessment was conducted 4 weeks later. The Generic Body-Focused Repetitive Behavior Scale (GBS) served as the primary outcome. The completion rate was best for DC-is (68.6%) as compared to HRT (57.1%) and DC (53.5%). A total of 34.8% of completers in the DC group showed an improvement of at least 35% on the GBS compared to 10.0% in the HRT and 23.3% in the DC-is group. In accordance with previous work, moderator analyses showed that improvement under DC is best for non-skin-pickers. A dose-effect relationship emerged, particularly for HRT. Subjective appraisal ratings were more favorable for DC-is and HRT than for DC. With respect to completion rate, subjective appraisal and symptom improvement, DC-is yielded consistently satisfactory results, whereas HRT showed good subjective but rather poor objective improvement. Those who performed DC, especially non-skin-pickers, showed good improvement but overall completion and subjective efficacy were low. Future studies should investigate whether the three techniques exert add-on effects when combined and whether demonstration via new media (e.g., video) will augment comprehensibility and thus efficacy of the techniques.