Motor Processing and Brain Activity Are Related to Cognitive-Behavioural Improvement Marc E. Lavoie Kieron P. O’Connor, Geneviève Thibault, Frederick Aardema, Marie-Claude Pélissier, Emmanuel Stip Louis-H Lafontaine Hospital University of Montréal Montréal, Québec, Canada

Definition of tic and habit disorders Chronic tic disorder (CTD): simple or complex repetitive muscle contraction Phonic Motor Habit disorders (HD): include destructive impulsive habits such as trichotillomania, onychophagia, scabiomania. Tics are defined as repetitive nonvoluntary contractions of functionally related groups of skeletal muscles in one or more parts of the body. Simple tics include blinking, cheek twitches, head or knee jerks, and shoulder shrugs.1–3 Complex tics involve sequences of movements and may also take the form of repetitive actions or mannerisms such as gestures and dystonic postures involving limbs, face, head, torso, or extremities. Habit Disorders (HD) is a term covering a variety of destructive impulsive habits including trichotillomania, bruxism, onychophagia, and scabiomania. TD and HD have been viewed as part of the Obsessive-Compulsive Disorder (OCD) spectrum.7 Although TD and HD have been compared independently with OCD, there has been little systematic inquiry into the common or distinguishing features between TD and HD

Neuropsychology and brain imaging Sensori-motor region subactivation. CTD impaired in visuo-motor performance and motor skills.(1) CTD and Tourette impaired in motor inhibition tasks.(2) CTD and HD showed similar lack of synchrony between cortical activity and motor preparation.(2) On the neuropsychological level, the most robust results involve trouble with visuo-motor integration. However, this problem could be subtended by other difficulties with attentional, visuo-spatial or inhibitory functions, as well as fine motor coordination. There is good reason to think that CTD patients are impaired in various aspects of motor functions such as : motor dexterity, inhibition and preparation. Bornstein et al. (1985, 1990, 1991) O’Connor et al. (2005); Channon et al. (2000); Hollander et al. (1990)

Neuropsychological rehabilitation in press First Questions … Study 1 CBT modifies motor performance in adults with chronic tic and habit disorder Neuropsychological rehabilitation in press Is there any differences in motor functions between CTD, HD and controls? Do CTD and HD react similarly to Cognitive-Behavioral Therapy? For this first section, there is two main questions we want to address. First: Is there any differences in motor functions between CTD and HD? And secondly: Do they react similarly to Cognitive-Behavioral Therapy?

Design Screening Chronic tic disorder Baseline Control Habit Disorders Random waitlist (33%) Baseline Cognitive-Behavioral Therapy Post-CBT evaluation (75%)

Demographic data Chronic tic (n=54) Habit disorder (n=51) Control ANOVA Age 39 37 38 ns F|M 21|33 31|20 21|11 Gen Health Quest 26 25 22 State anxiety 41 42 34 Trait anxiety 43 35 Overactivity -3 -2 8 * Beck depression 10 12 - Wisconsin card sorting test Normal

Symptom distribution Habit disorder Chronic tic disorder

Motor function measures Groove Purdue pegboard Hole steadiness

Hole Steadiness test (dominant hand) No group effect No CBT effect

Purdue pegboard (dominant hand) Significant difference between control and both client groups at baseline and waitlist. No difference between client groups. Significant improvement after CBT. Correlated with proportion of clinical change r = 0.26 r = 0.25 ANOVA: F[1,81] = 14.36, p<0.0001)

Groove test (dominant hand) Significant difference between control and CTD at baseline. No difference between client groups. Significant improvement after CBT for the CTD. * significant effect over time (F[1,80] = 4.23, p<0.04)

Conclusion (study 1) Intact function Impaired function Hole steadiness test regulation of position on the basis of proprioceptive feedback Impaired function Motor coordination and dexterity CTDs are mainly more impaired than HD. Purdue pegboard improvement correlated with symptom improvement.

Next Questions … Low to moderate symptoms Tourette syndrome ? Level of task complexity ? Motor inhibition and brain activity ?

Study 2 CBT Modifies Brain Activity Related to Motor Performance in Adults with Tourette Syndrome A pilot study

Demographic variables Demographic data Tourette Syndrome (n=10) Control (n=14) Mean σ T-Test p Demographic variables Age (years) 40 13 36 11 -0,77 ns Schooling (years) 15 3 2 -0,59 Raven intelligence (percentiles) 75 19 70 21 -0,65 Laterality (right %) 100 - Gender (M/F ratio) 7/3 9/5 Visual acuity (Snellen) 1,32 0,38 1,34 0,36 0,14 Colour perception (Ishihara) 10 2,49 0,51 0,79 Clinical Variables Tourette Syndrome Global Scale 30 - 13 Beck depression (BDI) 6 4 -3,31 ** Beck anxiety (BAI) 9 5 -3,25 PADUA - OCD (Global) 32 22 12 8 -2,78

EEG recordings Purdue pegboard 32 EEG channels Event-Related Potentials Purdue pegboard

Stop Response GO

Automatic response

Complex response

Purdue pegboard Significant difference between TS and control pre CBT. Normalization of motor dexterity post-CBT. *

Conclusion (study 2) Intact function Impaired function Complex responses Intact ability to inhibit complex responses. Normal brain activity related to complex responses. Impaired function Automatic responses Lower brain activation related to inhibition of automatic responses. Impaired ability to inhibit automatic responses. Normalized brain activity post-CBT.

Final conclusion Tourette and CTD have similar impairment in motor dexterity. Impairment in motor inhibition after automatic motor responses. Could originate from dysfunction in the sensorimotor cortex in TS. Reversible after CBT.

Thanks for your attention Acknowledgments Canadian Institute for Health Research Fonds de la Recherche en Santé du Québec