Biofeedback-Based Videogame May Improve Rage Attacks in Tourette Syndrome

Approximately 20%-40% of individuals with Tourette syndrome (TS) have rage attacks (RAs), which are recurrent, explosive behavioral outbursts that can cause significant functional impairment. Despite the impact of RA in TS, there has been limited research on treatment, and most studies have focused on pharmacologic interventions. Nonpharmacologic interventions have the potential to improve symptoms with fewer side effects. Mightier, a video game-based biofeedback therapy, may help teach emotional regulation through heart rate control and has the potential to improve RA in youth with TS. To evaluate the feasibility and acceptability of Mightier as a therapeutic intervention for RA in youth with TS. Subjects aged 6-12 years old with a diagnosis of TS and RA were enrolled between October 2021 and May 2022 into a 20-week single-arm trial. Feasibility was assessed by the rate of enrollment, screen failures, and retention and device engagement. We also evaluated efficacy by assessing rage severity (Clinical Global Impressions of Rage), Rage Outbursts and Anger Rating Scale (ROARS) and overall aggression severity (Modified Overt Aggression Scale [MOAS]) pre- and postintervention. CGI-Improvement (CGI-I) was completed postintervention. We enrolled 11 participants. The study was feasible based on enrollment rate (one participant every 2.5 months), screen failures (n = 1), and retention rate (91%). Mean weekly play time was 38 (SD 18) minutes/week. No adverse effects were reported. Median rage severity scores improved across all assessment measures. All participants reported overall improvement on the post-intervention CGI-I. This Mightier study was feasible in terms of recruitment and retention. Participants with TS and RA used the device often and engaged with the device throughout the 12-week intervention period. Rage severity overall improved across the various outcome measures, and all participants had at least some improvement by parent report. Mightier may be a helpful tool for reducing rage severity in children with RA and TS.