Clinical Evaluation
This protocol is extracted from research article:
Blocking Tics in Gilles de la Tourette Syndrome
Front Neurol, May 31, 2021; DOI: 10.3389/fneur.2021.686785

All patients were recruited from a single outpatient clinic and were personally reviewed and evaluated by a single clinician well-experienced in tic disorders (PJ). The patients were registered in the study only once, and no additional clinical data obtained in follow-up visits were included in the analysis.

The patients were diagnosed with GTS in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). All patients were systematically interviewed with the aid of a semi-structured interview comprised of demographic and clinical data which was gathered for all of the patients. This questionnaire is based on the TIC (Tourette syndrome International database Consortium) Data Entry Form, developed by Freeman et al. (9), in which study the investigator (PJ) participated and subsequently uses this form in his own clinical practice. This interview had been slightly modified over time and expanded to include questions regarding different types of tics, including BTs (each symptom was scored as either present or absent).

BTs were defined as sudden and transient cessation of motor activity with maintained consciousness (2). The diagnosis of BTs was based on the interview, occurrence during the examination, or provided video recordings. We actively asked the patients if they had experienced motor blocks in the past or at present (within the last 7 days). Based on our experience, we distinguished four activities that we asked for regarding BTs phenomenon: walking, running, speech and writing. We did not analyze primary and secondary tics separately because, due to recall bias, many patients were unable to precisely describe their symptoms and did not remember whether a BT was related to another tic or not. Therefore, we combined both of these blocking phenomena into one group of BTs. We excluded OCD-related blocking phenomena resulting from severe, time-consuming obsessions or mental compulsions (e.g., counting, checking, “just right phenomenon”) which usually lasted much longer compared to BTs and were better explained by OCD symptoms. If we suspected a functional nature of blocking phenomena these patients were also excluded from the study.

The described phenomena are illustrated by the attached videos. Supplementary Video 1 shows an 11-year-old girl with multiple motor BTs. In the Supplementary Video 2 patient with severe phonic BTs is presented. The Supplementary Video 3 shows a patient with OCD-related motor blocks, and although such patients were not included into our study, the differential diagnosis between BTs and OCD-related blocking phenomena is essential.

The Yale Global Tic Severity Scale (YGTSS) was used to assess the severity of tics within the last week before the clinical evaluation (10). The total number of simple tics and total number of complex tics were counted for each patient based on a tic symptom checklist included in the YGTSS. To assess the lifetime intensity of tics we questioned about worst ever tic severity and qualified it as mild, moderate, or severe. Mild tics were defined as not related to physical or mental discomfort, problems in relations with peers, less than expected academic achievements and the need for treatment. Tics were assign as moderate if they generated only slight and temporary restrictions in the patients' daily lives (e.g., a few days' absence from school, as well as difficulties with homework). Tics classified as severe were those that caused an inability to continue normal daily activities (e.g., repeating grades, losing one's job or physical discomfort), a significant deterioration in the quality of life and the necessity of pharmacological therapy. We also collected information about the presence of premonitory urges.

To make a diagnosis of OCD, each patient was carefully questioned about obsessions and compulsions according to the checklist included in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Then we analyzed if any of the present symptoms fulfilled the diagnostic criteria for OCD listed in the DSM-5. If a diagnosis of OCD had been made in psychiatric clinics before our evaluation, it was accepted and included into the analysis.

Different methods of data collecting were applied to children and adult patients. In contrast to children and adolescents, in whom most clinical information was provided by their parents, adults reported them themselves. All questions asked during the interview were part of routine practice and therefore no refusal rate is reported in this study.

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