Methods of diagnosing and treating tourette syndrome

Abstract

To provide methods of diagnosing and treating Tourette syndrome.SOLUTION: Methods and uses for diagnosing and treating Tourette syndrome are encompassed. The diagnosis and treatment may be based upon an assessment of genetic alterations in metabotropic glutamate receptor (mGluR) network genes and the treatment is with nonspecific activators of mGluRs such as Fasoracetam.SELECTED DRAWING: None

Description

[Technical Field]

[0001] Cross-reference to related applications This application claims priority to four U.S. provisional patent applications, including U.S. Provisional Patent Application Nos. 62 / 215628, 62 / 215633, 62 / 215636, and 62 / 215673, each filed on September 8, 2015, each of which is incorporated herein by reference in its entirety.

[0002] This application relates to the treatment of Tourette's syndrome with non-selective activators of metabotropic glutamate receptors (mGluRs), as well as the diagnosis and treatment of Tourette's syndrome in subjects with genetic alterations, e.g., copy number variations (CNVs), in one or more mGluR network genes. [Background technology]

[0003] Tourette syndrome (TS) is a neurological disorder characterized by tics, which are involuntary vocalizations or repetitive, purposeless movements. It is estimated that up to 200,000 Americans have the most severe form of TS, and as many as 1 in 100 Americans exhibit milder, more simple TS symptoms, which may include chronic motor or vocal tics. See the NIH Handbook on Tourette Syndrome (2012). The prevalence of TS is estimated to be 0.3% among US children aged 6-17 years, although there are suggestions that this may be an underestimate of its prevalence. See Cohen S et al., Neurosci Biobehav Rev. 37(6):997-1007 (2013).

[0004] Onset of TS symptoms usually occurs between the ages of 3 and 9, with men affected approximately 3-4 times more often than women. For many patients, TS is a chronic, lifelong condition with symptoms peaking in the teenage years. Simple tics of TS may involve eye blinking, head bobbing, or repetitive mumbling, while complex tics involve several muscle groups and may include jumping, twisting, or vocalizing words or phrases. Tics may be disabling, for example, involving hitting oneself, sweating, or repeating someone else's words or phrases. It is estimated that 10%-15% of TS patients have a progressive or disabling disease process that continues into adulthood. See the NIH Handbook on Tourette Syndrome (2012).

[0005] In addition to tics, individuals with TS often experience other neurobehavioral symptoms, such as hyperactivity and impulsivity (e.g., attention-deficit hyperactivity disorder [ADHD]), reading and academic difficulties, obsessive-compulsive thoughts, and repetitive behaviors. It is estimated that 90% of individuals with TS suffer from comorbid neuropsychiatric disorders, with ADHD and obsessive-compulsive disorder (OCD) being the most common (Cohen 2013).

[0006] Individuals with both TS and ADHD are at significantly increased risk for academic and social impairments.

[0007] The diagnosis of TS can be based on the patient's medical history and the presence of tics over time. In children and adolescents, the Yale Global Tic Severity Scale can be used as a clinician's tic severity rating, assessing the number, frequency, intensity, complexity, and interference of motor and vocal tics. See Storch et al., Psychol. Assessment. 17(4):486-491. Due to the high incidence of OCD in TS patients, the Yale-Brown Obsessive-Compulsive Scale for Children can be used to assess the severity of obsessive-compulsive symptoms in children and adolescents with TS. See Scahill et al., J. Am. Acad. Child Adolesc. Psychiatry. 36(6):844-852 (1997).

[0008] There are currently no medications that are helpful for all TS patients. While psycholeptics (i.e., antipsychotics) have been effective in treating tics in some patients, these medications have significant side effects and do not completely eliminate tic symptoms. In addition, treating neurobehavioral disorders associated with TS, such as ADHD, can be complicated because some medications used to treat ADHD are contraindicated in TS patients (see Ritalin prescribing information (2013)). Therefore, new therapies are needed to treat the full range of TS symptoms, including tics and neurobehavioral disorders. Summary of the Invention

[0009] As described herein, the inventors have studied the genotypes of over 90 patients diagnosed with Tourette's syndrome (TS) and found that these patients have a significantly higher frequency of genetic alterations in one or more metabotropic glutamate receptor (mGluR) network genes than historical controls. The frequency of genetic alterations in mGluR network genes was substantially higher in this TS population than in control populations without other neuropsychological disorders.

[0010] Thus, provided herein are methods for treating TS in a subject, comprising administering to the subject an effective amount of a non-selective activator of metabotropic glutamate receptors (mGluRs), thereby treating TS. In some embodiments, the subject has at least one genetic alteration, e.g., copy number variation (CNV), in an mGluR network gene. In some embodiments, the subject to be treated has been diagnosed with TS by any TS diagnostic method known in the art, including meeting criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) for the diagnosis of Tourette's syndrome. In some embodiments, a diagnosis of TS is made if the subject is found to have at least one genetic alteration in an mGluR network gene. In some embodiments, a diagnosis of TS is made if the subject is found to have at least one genetic alteration in an mGluR network gene and if the subject is found to have at least one symptom of TS, including, but not limited to, motor tics, vocal tics, or motor-vocal tics.

[0011] Also provided are methods for treating TS, comprising administering an effective amount of a non-selective activator of metabotropic glutamate receptors (mGluRs) to a subject having at least one genetic alteration, e.g., a CNV, in an mGluR network gene, thereby treating TS. In some embodiments, the subject has a CNV in an mGluR network gene, the CNV is a duplication or deletion.

[0012] In some embodiments, the invention includes a method for treating TS in a subject with motor and / or vocal tics by administering an effective amount of a non-selective activator of metabotropic glutamate receptors (mGluRs). In some embodiments, the subject also has at least one genetic alteration in an mGluR network gene.

[0013] Also provided is a method of treating TS in a subject, comprising obtaining results from a genetic screen to determine whether the subject has a genetic alteration in an mGluR network gene, and if the results indicate that the subject has at least one genetic alteration in an mGluR network gene, treating the subject by administering an effective amount of a non-selective activator of mGluR.

[0014] In some embodiments of the above methods, the non-selective mGluR activator is fasoracetam, e.g., fasoracetam monohydrate (NS-105 or NFC-1). In some embodiments, fasoracetam is administered at a dose of 50 mg, 100 mg, 150 mg, 200 mg, 250 mg, 300 mg, 350 mg, or 400 mg, administered once, twice, or three times daily. In some embodiments, fasoracetam is administered at a dose of 50-400 mg, 100-400 mg, or 200-400 mg, administered once, twice, or three times daily. In some embodiments, fasoracetam is administered at a dose of 200-400 mg, e.g., 200 mg, 300 mg, or 400 mg, administered twice daily.

[0015] In some embodiments, the method includes determining whether the subject has a genetic alteration, e.g., a CNV, in an mGluR network gene based on the results of the screening. In some embodiments of the above methods, the subject has a CNV in at least 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 mGluR network genes. In some embodiments, the CNV in an mGluR network gene is determined by obtaining a nucleic acid-containing sample from the subject and subjecting the sample to a screen that evaluates CNV in at least 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, or all Tier 1 mGluR network genes. In some embodiments, the CNV in an mGluR network gene is determined by obtaining a nucleic acid-containing sample from the subject and subjecting the sample to a screen that evaluates CNV in at least 50, at least 100, at least 150, at least 175, or all Tier 2 mGluR network genes. In some embodiments, CNVs in mGluR network genes are determined by obtaining a nucleic acid sample from a subject and subjecting the sample to a screen that evaluates CNVs in at least 50, at least 100, at least 200, at least 300, at least 400, at least 500, or all Tier 3 mGluR network genes. In some embodiments, the screen does not evaluate CNVs in one or more of GRM1, GRM2, GRM3, GRM4, GRM5, GRM6, GRM7, or GRM8. In certain aspects, the subject does not have a CNV in one or more of GRM1, GRM2, GRM3, GRM4, GRM5, GRM6, GRM7, or GRM8.

[0016] In some embodiments of the above methods, the TS is one or more of persistent (chronic) motor tic disorder, persistent (chronic) vocal tic disorder, or transitional tic disorder. In some embodiments, the method reduces the frequency and / or severity of tics in the subject. In some embodiments, the method reduces other behavioral symptoms, such as inattention, hyperactivity, and / or impulsivity. In some embodiments, the method also includes assessing tic symptoms in the subject, e.g., tic frequency, type (e.g., vocal or motor), and / or severity, as well as inattention, hyperactivity, and / or impulsivity, e.g., during or after administration, to determine whether one or more of these symptoms have been reduced in the subject. In some methods, such assessment can be performed based on the Yale-Brown Childhood Obsessive-Compulsive Scale and / or the Tourette Syndrome Clinical Rating Scale. In some embodiments, the method further includes obtaining a Clinical Global Impression of the subject's severity or improvement during or after administration. In some embodiments, the method can improve the subject's Clinical Global Improvement (CGI) score.

[0017] In some embodiments, the subject is a child or adolescent subject, e.g., a child or adolescent subject between the ages of 5 and 17, between 5 and 8, between 8 and 17, between 8 and 12, between 12 and 18, between 13 and 18, or between 12 and 17. In other embodiments, the subject is an adult.

[0018] In some embodiments of the above methods, the non-selective activator of mGluRs is administered in combination with another drug, such as an antipsychotic, or a non-drug therapy, which may include brain stimulation, such as vagus nerve stimulation, repetitive transcranial magnetic stimulation, magnetoconvulsive therapy, or deep brain stimulation.

[0019] In some embodiments, tic symptoms in a TS subject, such as tic frequency or the degree of movement for motor tics or the intensity of speech tics, are reduced in the subject, hi some embodiments, symptoms of inattention, hyperactivity, and / or impulsivity are reduced in the subject.

[0020] Also provided herein is a method for diagnosing TS in a subject, comprising isolating a nucleic acid-containing sample from the subject, analyzing the sample for the presence or absence of a genetic alteration in at least one mGluR network gene, and diagnosing TS if the subject has at least one genetic alteration in an mGluR network gene. Also provided is a method for diagnosing TS in a subject, comprising isolating a nucleic acid-containing sample from the subject, isolating nucleic acid from the sample, analyzing the nucleic acid for the presence or absence of a genetic alteration in at least one mGluR network gene, and diagnosing TS if the subject has at least one genetic alteration in an mGluR network gene. Also provided is a method for identifying a subject as having TS, comprising obtaining a sample from a patient, optionally isolating nucleic acid from the sample, optionally amplifying the nucleic acid, and analyzing the nucleic acid in the sample for the presence or absence of at least one mGluR network genetic alteration, e.g., CNV, wherein the subject is identified as having TS if at least one genetic alteration, e.g., CNV, in an mGluR network gene is detected. Additionally, a method for diagnosing TS in a subject is provided, comprising analyzing genetic information for about one or more mGluR network genes, comparing the subject's information with a control subject without TS, and diagnosing TS if the genetic information suggests that the subject has at least one genetic alteration in an mGluR network gene.

[0021] Also provided herein is a method of confirming a diagnosis of TS in a subject, the method comprising obtaining a nucleic acid-containing sample from a subject diagnosed with TS by a method that does not include detecting or analyzing a genetic alteration in an mGluR network gene, optionally amplifying nucleic acid in the sample, and determining whether the subject has at least one genetic alteration, e.g., a CNV, in an mGluR network gene, and confirming the diagnosis of TS if the subject has at least one genetic alteration in an mGluR network gene.

[0022] In any of the above methods, analysis of mGluR network genes for the presence or absence of at least one genetic alteration can include microarray, whole genome sequencing, exome sequencing, targeted sequencing, FISH, comparative genomic hybridization, genome mapping, or other methods using next generation sequencing, Sanger sequencing, PCR, or TaqMan technology.

[0023] In some embodiments, the subject has CNV in one, two, or more mGluR network genes. In some embodiments, the method comprises detecting CNV in mGluR network genes by subjecting the sample to a screen that assesses CNV in at least 2, 3, 4, 5, 6, 7, 8, 9, or 10 mGluR network genes. In some embodiments, CNV in mGluR network genes is determined by subjecting the sample to a screen that assesses CNV in at least 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, or all Tier 1 mGluR network genes. In some embodiments, CNV in mGluR network genes is determined by subjecting the sample to a screen that assesses CNV in at least 50, at least 100, at least 150, at least 175, or all Tier 2 mGluR network genes. In some embodiments, the CNV of mGluR network genes is determined by subjecting the sample to a screen that evaluates the CNV of at least 50, at least 100, at least 200, at least 300, at least 400, at least 500, or all Tier 3 mGluR network genes.

[0024] In some embodiments of the above methods, the TS is one or more of persistent (chronic) motor tic disorder, persistent (chronic) vocal tic disorder, or transitional tic disorder. In some embodiments, the subject is a child or adolescent subject, e.g., between the ages of 5 and 17, between the ages of 5 and 8, between the ages of 8 and 17, between the ages of 8 and 12, between the ages of 12 and 18, between the ages of 13 and 18, or between the ages of 12 and 17. In other embodiments, the subject is an adult subject.

[0025] In some embodiments, screening methods for determining the presence or absence of at least one mGluR network gene genetic alteration include microarray, whole genome sequencing, exome sequencing, targeted sequencing, FISH, comparative genomic hybridization, genome mapping, or other methods using next generation sequencing, Sanger sequencing, PCR, or TaqMan technology.

[0026] In some embodiments, the subject is not evaluated for genetic alterations or CNVs in one or more of GRM1, GRM2, GRM3, GRM4, GRM5, GRM6, GRM7, and GRM8. In some embodiments, the subject does not have a CNV in one or more of GRM1, GRM2, GRM3, GRM4, GRM5, GRM6, GRM7, and GRM8. In some embodiments, the subject does not have a CNV in any of GRM1, GRM2, GRM3, GRM4, GRM5, GRM6, GRM7, and GRM8.

[0027] In any of the methods and embodiments described in the preceding paragraphs of this Summary of the Invention, the subject may have TS and one or more co-morbid conditions, such as attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder, anxiety disorder, autism, mood disorder, schizophrenia, obsessive-compulsive disorder (OCD), anger control difficulties, disruptive behavior symptoms, self-injurious dermatopathy, developmental disorder, co-morbid movement disorder, or depression. In other cases, the subject does not have one or more of ADHD, ODD, conduct disorder, anxiety disorder, phobia, autism, mood disorder, schizophrenia, and depression. In still other cases, the subject does not have any of ADHD, ODD, conduct disorder, anxiety disorder, phobia, autism, mood disorder, schizophrenia, obsessive-compulsive disorder (OCD), anger control difficulties, disruptive behavior symptoms, self-injurious dermatopathy, developmental disorder, co-morbid movement disorder, or depression.

[0028] In one embodiment, a method for diagnosing an mGluR-related disorder is provided, wherein a subject is diagnosed with an mGluR-related disorder if at least one genetic alteration in an mGluR network gene is detected.

[0029] Additional objects and advantages will be set forth in part in the description which follows, and in part will be obvious from the description, or may be learned by practice. These objects and advantages will be realized and attained by means of the elements and combinations particularly pointed out in the appended claims.

[0030] It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive of the scope of the present invention.

[0031] The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate one or more embodiments and together with the description serve to explain the principles described herein. [Brief explanation of the drawings]

[0032] [Figure 1]Figure 1 shows the mGluR network genes included in the Tier 1 gene set. These genes have a protein-protein interaction degree of 2 with mGluR genes (GRM1-8) based on Cytoscape Human Interactome, a software for integrating biomolecular interaction networks with high-throughput data (described in Shannon P (2003) Genome Research 13:2498-2504). The Tier 1 gene set contains 76 genes. The exact locus for each gene in Tier 1 is listed in both Human Genome version 18 (hg18) and Human Genome version 19 (hg19). In addition, hg19 lists the exact gene locus +500 kb (i.e., ranging from 500 kb before to 500 kb after the gene of interest). The first single nucleotide polymorphism (StartSNP) (i.e., a SNP located 500 kb before the gene of interest) and the EndSNP (i.e., a SNP located 500 kb after the gene of interest) are also listed. The mGluR gene itself is designated "GRM." The expansion region (i.e., upstream and downstream of the 500 kb) often carries regulatory elements that, if affected by CNVs, can have the same effect on gene expression as CNVs present in the gene sequence itself. [Figure 2]This figure shows the mGluR network genes included in the Tier 2 gene set. These genes have a protein-protein interaction degree of 2 with mGluR genes (GRM1-8) based on Cytoscape Human Interactome, but do not include genes from Tier 1. The Tier 2 gene set includes 197 genes. The exact locus for each Tier 2 gene is listed in both Human Genome version 18 (hg18) and Human Genome version 19 (hg19). In addition, hg19 lists the exact gene locus +500 kb (i.e., ranging from 500 kb before to 500 kb after the gene of interest). The first single nucleotide polymorphism (StartSNP) (i.e., a SNP located 500 kb before the gene of interest) and EndSNP (i.e., a SNP located 500 kb after the gene of interest) are also listed in hg19. [Figure 3] This figure shows the genes in the Tier 3 gene set. Based on Cytoscape Human Interactome, genes with a protein-protein interaction level of 2 with mGluR genes are included. Genes included in Tier 1 and 2 are excluded from Tier 3. The Tier 3 gene set includes 599 genes. The exact locus for each Tier 3 gene is listed in both Human Genome Version 18 (hg18) and Human Genome Version 19 (hg19). In addition, hg19 lists the exact gene locus +500 kb (i.e., the range from 500 kb before to 500 kb after the gene of interest). The Start SNP (i.e., the SNP located 500 kb before the gene of interest) and End SNP (i.e., the SNP located 500 kb after the gene of interest) are also listed in hg19. [Figure 4] Figure 1 shows the number of copy number variation (CNV) calls involving mGluR network genes in samples from 95 fully genotyped TS patients. Note that several patients had more than one CNV call involving an mGluR network gene. [Figure 5] FIG. 1 shows the percentage of fully genotyped TS patients who had CNVs within the Tier 1, Tier 1+2, or Tier 1+2+3 mGluR network gene sets. DETAILED DESCRIPTION OF THE INVENTION

[0033] I. Definition In addition to the definitions contained in this subsection, further definitions of terms are scattered throughout this document.

[0034] In the present invention, unless the context clearly dictates otherwise, "a" or "an" means "at least one" or "one or more," etc. The term "or" means "and / or," unless otherwise indicated. However, in the case of multiple dependent claims, the use of the term "or" refers back to more than one preceding claim and exclusively as an alternative to that claim.

[0035] "mGluR," or metabotropic glutamate receptor, refers to one of eight glutamate receptors expressed in neural tissue, named mGluR1, mGluR2, mGluR3, mGluR4, mGluR5, mGluR6, mGluR7, and mGluR8. Their genes are abbreviated as GRM1 through GMRM8. mGluR proteins are G protein-coupled receptors. They are typically classified into three subgroups: Group I receptors, including mGluR1 and mGluR5, are classified as slow excitatory receptors; Group II includes mGluR2 and mGluR3; and Group III includes mGluR4, mGluR6, mGluR7, and mGluR8. Groups II and III are classified as slow inhibitory receptors. mGluRs are distinct from ionotropic GluRs or iGluRs, which are ionotropic glutamate receptors and are classified as fast excitatory receptors.

[0036] "mGluR network genes," as used herein, include not only the mGluRm genes GRM1, GRM2, GRM3, GRM4, GRM5, GRM6, GRM7, and GRM8, but also each of the other genes listed in Figures 1-3 herein, as well as regions of DNA that regulate the genes listed in Figures 1-3. Additionally, "mGluR network proteins" are proteins encoded by mGluR network genes.

[0037] The mGluR network genes are classified into three subsets: Tier 1, Tier 2, and Tier 3 (see Figures 1-3). The Tier 1 mGluR network genes shown in Figure 1 contain 76 genes, including several GRM genes themselves as well as numerous other genes. The Tier 2 mGluR network genes shown in Figure 2 contain 197 genes and do not include Tier 1 genes.

[0038] Both Tier 1 and Tier 2 are included in the "primary mGluR network." The "primary network" of mGluR genes totals 276 genes and also includes the genes 4-Sep, LOC642393, and LOC653098. Evaluation of the 4-Sep, LOC642393, and LOC653098 genes is difficult with current technology. Therefore, although they are not included in Tier 1 or Tier 2, they are included in the primary network of genes of the present invention. Tier 1 and 2 genes differ in that alterations in Tier 1 genes have been documented in previous genotyping studies of subjects suffering from psychiatric disorders.

[0039] The Tier 3 mGluR network genes shown in Figure 3 include 599 genes in the distal part of the mGluR network based on the merged human interactome provided by Cytoscape software (Shannon P et al. (2003) Genome Research 13:2498-2504), excluding Tier 1 and Tier 2 genes. Therefore, Tier 3 genes are part of the "distal mGluR network." In addition to Tier 3 genes, genes LOC285147, LOC147004, and LOC93444 are also included in the "distal mGluR network." However, due to technical challenges in assessing genetic alterations in these genes, they were not evaluated in this study and are not included in Tier 3.

[0040] As used herein, "genetic alteration" refers to any change in the DNA of a gene or in the DNA regulating a gene. A genetic alteration can result in, for example, a functionally altered gene product compared to a gene product produced from unaltered DNA. A functional alteration can be, for example, a different expression level (up-regulation or down-regulation), or a loss or alteration of one or more biological activities. Genetic alterations include, but are not limited to, copy number variations (CNVs), single nucleotide variants (SNVs), also referred to herein as single nucleotide polymorphisms (SNPs), frameshift mutations, or any other base pair substitutions, insertions, deletions, or duplications.

[0041] "Copy number variation" or "CNV" refers to the duplication or deletion of a DNA segment relative to a reference genome, where the DNA segment encompasses a gene, genes, a segment of a gene, or a DNA region regulating a gene. In some embodiments, CNV is determined based on a change from the normal diploid state. In some embodiments, CNV refers to a copy number change involving a DNA fragment that is 1 kilobase (kb) or larger. CNVs as described herein do not include variants resulting from the insertion / deletion of transposable elements (e.g., 6 kb KpnI repeats). Thus, the term CNV encompasses terms such as large copy number variation (LCV; Iafrate et al., 2004), copy number polymorphism (CNP; Sebat et al., 2004), and intermediate-sized variant (ISV; Tuzun et al., 2005), but does not encompass retrotransposon insertions.

[0042] A "CNV deletion" or "deletion CNV" or similar terms refers to a CNV in which a gene, a DNA segment regulating a gene, or a gene segment is deleted. A "CNV duplication" or "duplication CNV" or similar terms refers to a CNV in which a gene, a DNA segment regulating a gene, or a gene segment is present in at least two copies, and possibly more than two copies, compared to the single copy found in a normal reference genome.

[0043] "Sample" refers to a sample from a subject that can be tested, for example, for the presence of a CNV in one or more mGluR network gene proteins, as described herein. A sample can include cells or a bodily fluid, such as blood, serum, plasma, cerebrospinal fluid, urine, saliva, tears, pleural fluid, etc.

[0044] Tourette's syndrome is described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5, 2013) as a disorder characterized by the presence of both multiple motor tics and one or more vocal tics, symptoms of which persist for more than one year. A tic is a sudden, rapid, repetitive, non-rhythmic motor movement or vocalization. Symptoms typically manifest before the age of 18. As used herein, the term "Tourette's syndrome" includes each of "persistent (chronic) motor tic disorder," "persistent (chronic) vocal tic disorder," "provisional tic disorder," and "tic disorder." Patients with Tourette's syndrome may have both motor and vocal tic symptoms that have been present for at least one year. However, patients with "tic disorder" may have only motor tics or only vocal tics. Patients with "persistent (chronic) motor tic disorder" may have only motor tics. Patients with "persistent (chronic) vocal tic disorder" may have only vocal tics. Patients with "provisional tic disorder" may have symptoms for less than a year.

[0045] Patients with TS may also have inattention, hyperactivity, anxiety, mood, and sleep disorders. Currently, TS can be diagnosed using one or more rating scales, such as the Yale Global Tic Severity Scale, as described in Storch 2005.

[0046] The terms "subject" and "patient" are used interchangeably to refer to a human.

[0047] The terms "pediatric subject" or "pediatric patient" are used interchangeably to refer to a human under the age of 18. An "adult patient" or "adult subject" refers to a human aged 18 or older. An "adolescent patient" or "adolescent subject" is typically a subject between about 12 and 18 years of age, e.g., between 12 and 17 years of age, or between 13 and 18 years of age.

[0048] II. How to diagnose Tourette's syndrome In some embodiments, the present invention includes a method of diagnosing TS in a subject, comprising analyzing the subject's genetic information to determine whether the subject has a genetic variation in at least one mGluR network gene, and diagnosing the subject as having TS if a genetic variation is found. In some embodiments, the subject has TS but does not have ADHD, oppositional defiant disorder (ODD), conduct disorder, anxiety disorder, phobia, autism, mood disorder, schizophrenia, obsessive-compulsive disorder (OCD), anger control difficulties, disruptive behavior symptoms, self-injurious dermatopathy, another movement disorder, developmental disorder, or depression. In some embodiments, the subject has TS and also has one or more of ADHD, conduct disorder, anxiety disorder, phobia, autism, mood disorder, schizophrenia, obsessive-compulsive disorder (OCD), anger control difficulties, disruptive behavior symptoms, self-injurious dermatopathy, another movement disorder, developmental disorder, or depression. In some embodiments, the subject has both TS and ADHD.

[0049] As used herein, "developmental disorders" include, for example, those classified under International Classification of Diseases, Ninth Revision (World Health Organization) codes 299.80, 299.90, 315.2, 315.39, 315.4, 315.5, 315.8, and 315.9, which may affect behaviors such as learning, coordination, and speech. "Self-injurious dermatopathy," also known as excoriation disorder or skin picking disorder, is a disorder involving excessive picking of one's own skin, resulting in damage, and includes picking at intact skin as well as real or imagined skin defects, such as moles, freckles, or scars.

[0050] In other embodiments, the present invention encompasses confirming a diagnosis of TS in a subject. As used herein, "confirming a diagnosis of TS" refers to diagnosing a subject already diagnosed with TS. In some embodiments, a method of confirming a diagnosis of TS involves analyzing genetic information of a subject diagnosed with TS by a method that does not involve analyzing mGluR network genes to determine whether the subject has a genetic variation in at least one mGluR network gene, and confirming the diagnosis of TS if a genetic variation in at least one mGluR network gene is found. In some embodiments, screening for the presence of an mGluR network gene variation is one of two or more tests or assessments performed to confirm a diagnosis in a subject. In some embodiments, a subject has TS but does not have ADHD, ODD, conduct disorder, anxiety disorder, phobia, autism, mood disorder, or depression. In some embodiments, a subject has TS and also has one or more of ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, and depression. In some embodiments, the subject has both TS and ADHD.

[0051] In another embodiment, the invention comprises confirming a diagnosis of TS in a subject free of ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, and depression, comprising analyzing genetic information of a subject diagnosed with TS by a method that does not include analyzing mGluR network genes to determine whether the subject has a genetic variation in at least one mGluR network gene, and confirming the diagnosis of TS if a genetic variation in at least one mGluR network gene is found.

[0052] In one embodiment, TS is diagnosed and / or confirmed when at least one CNV, SNV, frameshift mutation, or any other base pair substitution, insertion, deletion, or duplication in an mGluR network gene is detected. In another embodiment, TS is diagnosed and / or confirmed when at least one CNV, SNV, frameshift mutation, or any other base pair substitution, insertion, or deletion in a Tier 1 mGluR network gene is detected. In another embodiment, TS is diagnosed and / or confirmed when at least one CNV, SNV, frameshift mutation, or any other base pair substitution, insertion, or deletion in a Tier 2 mGluR network gene is detected. In yet another embodiment, TS is diagnosed and / or confirmed when at least one CNV, SNV, frameshift mutation, or any other base pair substitution, insertion, or deletion in a Tier 3 mGluR network gene is detected.

[0053] The diagnosis or confirmation of TS can be based on or confirmed by finding a genetic alteration in Tier 1, Tier 2, and / or Tier 3 mGluR network genes. The genetic alteration can be a CNV. A CNV can be a duplication or deletion of a DNA region containing some or all of the DNA encoding and controlling / regulating an mGluR network gene. In another embodiment, the diagnosis or confirmation of a diagnosis of TS is made in a patient who does not have ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, or depression. In some embodiments, the diagnosis or confirmation of a diagnosis of TS is made in a patient who has TS and one or more of ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, autism, mood disorder, phobia, and depression.

[0054] In some embodiments, the diagnosis or confirmation of a diagnosis of TS is based on finding that the copy number of mGluR network genes deviates from the normal diploid state. In some embodiments, the diagnosis or confirmation of a diagnosis of TS is based on a copy number of 0 or 1, indicating a CNV deletion. In some embodiments, the diagnosis or confirmation of a diagnosis of TS is based on a copy number of 3 or more, indicating a CNV duplication. In other embodiments, the diagnosis or confirmation of a diagnosis of TS is made by the presence of a copy number of 0 or 1, or a copy number of 3 or more, or any deviation from the diploid state in patients without ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, and depression.

[0055] In one embodiment, a diagnosis of a more severe form of TS is made when at least two CNVs in mGluR network genes are detected. In one embodiment, a more severe form of TS in a patient without ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, or depression is diagnosed when at least two CNVs in mGluR network genes are detected.

[0056] In one embodiment, a method for diagnosing TS and / or confirming an anxiety disorder comprises obtaining a nucleic acid-containing sample from a subject; optionally amplifying the nucleic acid; optionally labeling the nucleic acid sample; applying the nucleic acid to a solid support comprising one or more nucleic acids of an mGluR network gene, the nucleic acid optionally comprising an SNV of an mGluR network gene; removing any unbound nucleic acid sample; and detecting any nucleic acid bound to the nucleic acid on the solid support, wherein if bound nucleic acid is detected, the patient is diagnosed or confirmed as having TS. In one embodiment, the method further comprises comparing any bound nucleic acid with a standard or control, and diagnosing or confirming TS if analysis reveals that the test sample is different from the control or standard. In another embodiment of this method, the patient with TS does not have ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, autism, mood disorder, phobia, or depression. In another embodiment, the TS patient also has one or more of ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, or depression.

[0057] In each of the diagnostic, confirmatory, and treatment methods of the invention, the disorder can be TS, persistent (chronic) vocal tic disorder, persistent (chronic) motor tic disorder, or provisional tic disorder. In each of the diagnostic, confirmatory, and treatment methods of the invention, the subject has TS but does not have ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, or depression. In other diagnostic, confirmatory, and treatment methods of the invention, the subject has TS and one or more additional disorders, such as ADHD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, or depression. In some methods, the subject has both TS and ADHD.

[0058] III. Methods and Uses for Treating Tourette's Syndrome

[0013] Contained herein are methods for treating TS in a subject, comprising administering an effective amount of a non-selective mGluR activator. As used herein, the term "treatment" includes any administration or application of a therapy for a disease or disorder in a subject, including suppressing the disease, preventing its onset, alleviating symptoms of the disease, or preventing the occurrence or recurrence of the disease or symptoms of the disease.

[0059] mGluR proteins are typically classified into three subgroups: Group I receptors, which include mGluR1 and mGluR5, are classified as slow excitatory receptors; Group II includes mGluR2 and mGluR3; and Group III includes mGluR4, mGluR6, mGluR7, and mGluR8. Groups II and III are classified as slow inhibitory receptors.

[0060] mGluRs are distinguished from ionotropic GluRs or iGluRs, which are ionotropic glutamate receptors and are classified as fast excitatory receptors.

[0061] A "non-selective activator of mGluRs" refers to a molecule that activates mGluRs from more than one of the Group I, II, and III categories. Thus, a non-selective activator of mGluRs can provide a general stimulus to the mGluR network. This is in contrast to a specific mGluR activator that can only significantly activate a single mGluR, such as mGluR5. Non-selective mGluR activators include, for example, non-selective mGluR agonists.

[0062] In some embodiments, the non-selective mGluR activator is fasoracetam. Fasoracetam is a nootropic (i.e., cognitive-enhancing) drug that can stimulate both group I mGluRs and group II / III mGluRs in in vitro studies. (See Hirouchi M et al. (2000) European Journal of Pharmacology 387:9-17.) While fasoracetam can stimulate adenylate cyclase activity by activating group I mGluRs, it can also inhibit adenylate cyclase activity by stimulating group II and III mGluRs. (Oka M et al. (1997) Brain Research 754:121-130.) Fasoracetam has been shown to be highly bioavailable (79%-97%) and has a half-life of 5-6.5 hours in previous human studies (see Malykh AG et al. (2010) Drugs 70(3):287-312). Fasoracetam is a member of the racetam family of chemicals, which share a five-carbon oxopyrrolidone ring.

[0063] The structure of fasoracetam is: The file is TIFF2025183206000001.tif22170.

[0064] The term "fasoracetam" as used herein encompasses pharma- ceutically acceptable hydrates and any solid, amorphous, or crystalline form of the fasoracetam molecule. For example, the term fasoracetam herein includes forms such as fasoracetam monohydrate NFC-1. In addition to NFC-1, fasoracetam is also known as C-NS-105, NS105, and LAM-105.

[0065] NFC-1 has previously been studied in Phase I-III clinical trials for dementia-related cognitive impairment, but Phase III trials did not demonstrate sufficient efficacy for dementia. These trials demonstrated that NFC-1 is generally safe and well-tolerated for these indications. Phase III data showed that NFC-1 has beneficial effects on psychiatric symptoms in patients with cerebral infarction and adult dementia patients with cerebrovascular disease.

[0066] In each method of treatment embodiment, a metabotropic glutamate receptor-positive allosteric modulator, a metabotropic glutamate receptor-negative allosteric modulator, or a tachykinin-3 / neurokinin-3 receptor (TACR-3 / NK3R) antagonist, alone or in combination with a non-selective activator of mGluR, can be administered to a subject with alterations in mGluR network genes, for example. In some embodiments, the therapeutic agent comprises ADX63365, ADX50938, ADX71149, AMN082, 1-(hetero)aryl-3-amino-pyrrolidine derivatives, LY341495, ADX48621, GSK1144814, or SB223412.

[0067] Also encompassed herein is a method for treating TS, comprising administering fasoracetam to a subject having a genetic alteration in at least one mGluR network gene. In some embodiments, the subject has TS but does not have ADHD, ODD, conduct disorder, anxiety disorder, autism, a mood disorder, phobia, schizophrenia, obsessive-compulsive disorder (OCD), anger control difficulties, disruptive behavior symptoms, self-injurious dermatopathy, another movement disorder, a developmental disorder, or depression, while in other embodiments, the subject has TS and at least one of ADHD, ODD, conduct disorder, anxiety disorder, autism, a mood disorder, phobia, schizophrenia, obsessive-compulsive disorder (OCD), anger control difficulties, disruptive behavior symptoms, self-injurious dermatopathy, another movement disorder, a developmental disorder, or depression. In some embodiments, the subject has both TS and ADHD.

[0068] In some embodiments, the treatment method comprises identifying or diagnosing a subject as having a genetic alteration in at least one mGluR network gene and administering a non-selective mGluR activator, such as fasoracetam, to the identified or diagnosed subject. In some embodiments, the subject has TS but does not have ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, or depression. In other embodiments, the subject has TS and also has one or more neuropsychological disorders, such as ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, and depression.

[0069] In each treatment method embodiment of the invention, the disorder may be TS, persistent (chronic) vocal tic disorder, persistent (chronic) motor tic disorder, or transitional tic disorder. In each treatment method, a non-selective mGluR activator, e.g., fasoracetam, may reduce the frequency or severity of the tics in a subject and / or improve symptoms of inattention, hyperactivity, anxiety, mood, and sleep disturbances that may be present in patients with TS or a tic disorder. For example, these symptoms may be alleviated after one week of treatment with the activator, e.g., after two weeks of treatment, after three weeks of treatment, or after four weeks of treatment.

[0070] In some embodiments, the subject has a co-morbid condition of anxiety, and optionally the method reduces the anxiety symptoms. In some embodiments, the subject has OCD, and optionally the method reduces the OCD symptoms. In some embodiments, the subject has a co-morbid condition of self-injurious dermatopathy, such as excessive skin picking, and optionally the method reduces those symptoms. In some embodiments, the subject has one or more co-morbid developmental disorders, and optionally the method reduces the severity of symptoms related to the developmental disorder.

[0071] In some embodiments, the subject may have one or more of the following symptomatic changes after at least 1, 2, 3, or 4 weeks of treatment with the activator: (a) the subject has symptoms of anger control and those anger control symptoms are reduced; (b) the subject has symptoms of disruptive behavior and those disruptive behavior symptoms are reduced; (c) the subject's CGI-I is reduced by at least 1 or at least 2; (d) the subject's CGI-I score after 1, 2, 3, or 4 weeks of treatment is 1 or 2; (e) the subject's CGI-S score after 1, 2, 3, or 4 weeks of treatment is 1; (f) the subject has ADHD and the subject's ADHD rating scale score is reduced by at least 25%, e.g., at least 30%, at least 35%, or at least 40%; (g) the subject has symptoms of inattentiveness and those symptoms are reduced. (h) the subject has symptoms of hyperactivity and the hyperactivity symptoms are reduced; (i) the subject has symptoms of impulsivity and the impulsivity symptoms are reduced; (j) the subject has symptoms of ODD, e.g., anger and irritability, argumentative and defiant attitudes, and / or vindictiveness, and the ODD symptoms are reduced; (k) the subject has symptoms of conduct disorder and the conduct disorder symptoms are reduced; (l) the subject has symptoms of anxiety and the anxiety symptoms are reduced; (m) the subject has symptoms of OCD and the OCD symptoms are reduced; (n) the subject has symptoms of autism and the autism symptoms are reduced; and (o) the subject has symptoms of a movement disorder other than Tourette's syndrome and the movement disorder symptoms are reduced.

[0072] In one embodiment, a non-selective mGluR activator such as fasoracetam is administered to a subject with TS who has been confirmed to have at least one genetic alteration in an mGluR network gene. The genetic alteration may be in a Tier 1 mGluR network gene. The genetic alteration may be in a Tier 2 mGluR network gene. The genetic alteration may be in a Tier 3 mGluR network gene. The genetic alteration may be more than one genetic alteration, and the more than one alteration may be in one of Tiers 1, 2, or 3, or any combination of Tiers.

[0073] Some embodiments include methods of treating TS, comprising obtaining genetic information about mGluR network genes in a subject, and administering a non-selective mGluR activator, such as fasoracetam, if the subject has at least one genetic alteration, e.g., a CNV, in an mGluR network gene. Other embodiments include methods of treating TS, comprising obtaining genetic information about mGluR network genes in a subject, and administering a non-selective mGluR activator, such as fasoracetam, if the subject has at least one genetic alteration, e.g., a CNV, in a Tier 1 mGluR network gene.

[0074] Another embodiment includes a method of treating TS comprising obtaining genetic information about mGluR network genes in a subject, and if the subject has at least one genetic alteration, e.g., a CNV, in a Tier 2 mGluR network gene, administering a non-selective mGluR activator, such as fasoracetam.

[0075] Yet other embodiments include methods of treating TS, comprising obtaining genetic information about mGluR network genes in a subject, and administering a non-selective mGluR activator, such as fasoracetam, if the subject has at least three genetic alterations, e.g., CNVs, in Tier 3 mGluR network genes.

[0076] Subjects with more than one CNV of any one tier, or a combination of any three tiers, can be treated by administering a non-selective mGluR activator such as fasoracetam.

[0077] In some embodiments, subjects can be treated who have TS but do not have ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, schizophrenia, anger control difficulties, disruptive behavior, symptoms, obsessive-compulsive disorder (OCD), self-injurious dermatopathy, developmental disorder, another movement disorder other than TS, and depression. In other treatment method embodiments of the invention, the subject has, in addition to TS, one or more neuropsychological disorders, such as ADHD, ODD, conduct disorder, anxiety disorder, autism, mood disorder, phobia, schizophrenia, anger control difficulties, disruptive behavior, symptoms, obsessive-compulsive disorder (OCD), self-injurious dermatopathy, developmental disorder, another movement disorder other than TS, and depression.

[0078] IV. Methods for determining the presence or absence of genetic alterations Any biological sample, including but not limited to blood, urine, serum, gastric washings, central nervous system fluid, any cell type (e.g., brain cells, white blood cells, mononuclear cells), or body tissue, can be used to determine the presence or absence of mGluR network genetic alterations. Any biological sample from which DNA can be extracted can be used to determine the presence or absence of mGluR network genetic alterations. The sample can be freshly collected or previously collected for any use / purpose and stored until the time to test for genetic alterations. Previously purified DNA for different purposes can also be used.

[0079] A variety of methods are known for determining genetic alterations, including the following:

[0080] A. Single Nucleotide Variant (SNV) / Single Nucleotide Polymorphism (SNP) Genotyping Determining whether a patient has a genetic alteration, e.g., a CNV, in an mGluR network gene can be performed by SNP / SNV genotyping. A "single nucleotide variant (SNV)," also referred to herein as a "single nucleotide polymorphism (SNP)," refers to a change in DNA in which a single base differs from the normal base at that position. Millions of SNVs in the human genome have been cataloged. Some SNVs are normal variations in the genome, while others are associated with disease. While certain SNVs may be associated with disease states or susceptibility, high-density SNV genotyping can be undertaken, in which sequencing information from SNVs is used to determine an individual's unique genetic makeup.

[0081] In SNV genotyping, SNVs can be determined by hybridizing complementary DNA probes to SNV sites. A wide range of platforms can be used with SNV genotyping tools to accommodate various sample throughputs, multiplexing capabilities, and chemistries. In high-density SNV arrays, hundreds of thousands of probes are arrayed on a small chip so that many SNVs can be interrogated simultaneously when target DNA is processed on the chip. Specific SNV alleles can be determined by determining the amount of hybridization of target DNA in a sample to probes (or redundant probes) on the array. The use of arrays for SNV genotyping enables large-scale interrogation of SNVs.

[0082] When analyzing CNV, after analyzing SNV, SNV data can be manipulated using computer programs to arrive at CNV data. In this case, PennCNV or similar programs can be used to detect signal patterns throughout the genome and identify continuous genetic markers related to copy number changes. (See Wang K et al. (June 2008) Cold Spring Harbour Protocol). PennCNV allows kilobase resolution detection of CNV (See Wang K et al. (Nov 2007) Genome Res.17(11):1665-74).

[0083] CNV analysis compares SNV genotyping data with the behavior of normal diploid DNA. The software uses SNV genotyping data to determine signal intensity data and the distribution of SNV allele ratios, and then uses these data to determine when there is a deviation from the normal diploid state of the DNA, indicating a CNV. This is done in part by using the log R ratio (LRR), a normalized measure of the total signal intensity for the two alleles of an SNV (Wang 2008). If the software detects a region of adjacent SNVs with an intensity (LRR) trending below zero, this indicates a CNV deletion. If the software detects a region of adjacent SNVs with an intensity (LRR) trending above zero, this indicates a CNV duplication. If no change in LRR is observed compared to the behavior of diploid DNA, the sequence is in a normal diploid state with no CNV present. The software also uses the B allele frequency (BAF), a normalized measure of the allele intensity ratio of two alleles, which changes when an allele is lost or gained, as well as when an allele is lost or gained, as well as when a CNV is lost or duplication. For example, CNV deletion is indicated by both a decrease in LRR value and the absence of heterozygotes in BAF value.In contrast, CNV duplication is indicated by both an increase in LRR value and the division of heterozygote genotype BAF cluster into two different clusters.The software automates the calculation of LRR and BAF to detect CNV deletion and duplication in whole genome SNV data.By simultaneously analyzing intensity data and genotype data, normal diploid state is accurately defined and CNV is determined.

[0084] Array platforms such as those from Illumina, Affymetrix, and Agilent can be used in SNV genotyping. Custom arrays can also be designed and used based on the data described herein.

[0085] B. Comparative Genomic Hybridization Comparative genomic hybridization (CGH) is another method that can be used to assess genetic alterations, such as CNVs. CGH is a molecular cytogenetic method that uses competitive fluorescence in situ hybridization (FISH) to analyze genetic alterations, such as CNVs, in comparison to a reference sample. DNA is isolated from the patient and reference source and, after DNA denaturation, independently labeled with fluorescent molecules (i.e., fluorophores). Hybridization of the fluorophores to the resulting samples is compared along the length of each chromosome to identify chromosomal differences between the two sources. Color discrepancies indicate gain or loss of material within specific regions of the test sample, while color matches indicate no difference in genetic alterations, such as copy number, between the test and reference samples in a particular region.

[0086] C. Comparative Genomic Hybridization Whole genome sequencing, whole exome sequencing, or targeted sequencing can also be used to analyze genetic changes such as CNVs. Whole genome sequencing (also known as full-length genome sequencing, complete genome sequencing, or whole genome sequencing) involves sequencing the full-length genome of a species, including protein-coding and non-coding genes. In contrast, whole exome sequencing is the sequencing of only protein-coding genes in the genome (approximately 1% of the genome). Targeted sequencing involves sequencing only selected parts of the genome.

[0087] A wide range of techniques will be known to those skilled in the art for performing whole genome, whole exome, or targeted sequencing using purified DNA from a subject. Similar techniques could be used for different types of sequencing.

[0088] Techniques used in whole genome sequencing include nanopore technology, fluorophore technology, DNA nanoball technology, and pyrosequencing (i.e., sequencing by synthesis). Specifically, next-generation sequencing (NGS) involves the parallel sequencing of millions of small fragments of DNA, followed by the use of bioinformatics analysis to piece together the sequencing data from the fragments.

[0089] Whole exome sequencing does not require the sequencing of a large amount of DNA, as in whole genome sequencing, so a wide range of techniques can be used.Methods for whole exome sequencing include polymerase chain reaction, NGS, molecular inversion probe, hybrid capture using macroarray, in-solution capture, and classical Sanger sequencing.Targeted sequencing allows obtaining sequence data for specific genes instead of the whole genome, and can use any technique used in other types of sequencing, including specialized microarrays that contain materials for sequencing the target gene.

[0090] D. Other Methods for Determining Genetic Alterations Proprietary methods, such as those from BioNano or OpGen, that use genome mapping technology can also be used to assess genetic alterations such as CNVs.

[0091] Genetic alterations such as CNVs can be assessed using standard molecular biology methods, such as quantitative polymerase chain reaction (PCR), droplet PCR, and TaqMan probes (i.e., hydrolysis probes designed to increase the specificity of quantitative PCR). Fluorescence in situ hybridization (FISH) probes may also be used to assess genetic alterations such as CNVs. Analysis of genetic alterations such as CNVs present in TS patients is not limited by the exact method used to determine genetic alterations such as CNVs.

[0092] V. Methods for diagnosing TS based on CNV data In some embodiments, the genetic variation is an SNV or CNV. The SNV or CNV associated with TS is found in an mGluR network gene, such as a gene listed in Tier 1, Tier 2, or Tier 3, as shown in Figures 1-3, or a set or panel of such genes.

[0093] In some embodiments, gene sets of mGluR network genes are used in the analysis of samples from patients with or suspected of having TS. In some embodiments, the presence of CNV duplications or deletions within these gene sets or panels is determined. In some embodiments, CNVs of the Tier 1 genes shown in FIG. 1 are determined. In some embodiments, a panel of at least 10, at least 20, at least 30, at least 40, at least 50, at least 60, at least 70, or all 76 Tier 1 genes is evaluated for the presence of CNVs. Within any such gene panel, specific individual Tier 1 genes may be excluded from the analysis set. For example, any or all of GRM1-8 may be excluded from the panel.

[0094] In some embodiments, Tier 2 genes, such as those shown in Figure 2, are analyzed for the presence of genetic alterations, such as CNVs. Tier 2 genes are closely related to mGluRs but are not included in Tier 1.

[0095] In some embodiments, Tier 2 genes are evaluated along with Tier 1 genes. In some embodiments, at least 100 Tier 2 genes are evaluated, while in some embodiments, at least 150 or 197 Tier 2 genes are evaluated. In some embodiments, individual specific Tier 2 genes may be excluded from the gene set for evaluation.

[0096] In some embodiments, 599 Tier 3 genes, such as those shown in Figure 3, are evaluated for the presence of genetic alterations such as CNVs. In some embodiments, Tier 3 genes are evaluated along with Tier 1 and / or Tier 2 genes. In some embodiments, at least 100 Tier 3 genes are evaluated, while in some embodiments, at least 150, 200, 250, 300, 350, 400, 450, or 599 Tier 3 genes are evaluated. In some embodiments, certain individual Tier 3 genes may be excluded from the gene set for evaluation.

[0097] VI. Administration Methods and Combination Therapies In some embodiments, the agent that modulates mGluR signaling is fasoracetam or fasoracetam monohydrate (also known as C-NS-105, NFC1, NS105, or LAM-105).

[0098] A. Medication In some embodiments, fasoracetam can be administered as fasoracetam monohydrate (NFC-1). In some embodiments, fasoracetam can be administered orally (i.e., orally). In some embodiments, fasoracetam can be administered as a capsule. In some embodiments, fasoracetam capsules can contain 50, 60, 70, 80, 90, 100, 110, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195, or 200 mg of fasoracetam monohydrate. In some embodiments, fasoracetam can be administered once daily or twice daily. In some embodiments, the daily dose of fasoracetam can be 50 mg once daily, 100 mg once daily, 200 mg once daily, 400 mg once daily, 50 mg twice daily, 100 mg twice daily, 200 mg twice daily, or 400 mg twice daily. In some embodiments, a series of dose escalations can be used to adjust fasoracetam dosing. In some embodiments, pharmacokinetic data on drug levels or clinical response are used to determine changes in dosing. In some embodiments, dose escalation of fasoracetam is not used. In some embodiments, subjects are treated with a fasoracetam dose expected to be clinically effective without a dose escalation protocol.

[0099] B. Combination Therapy In some embodiments, fasoracetam is used in combination with other drugs for the treatment of TS. The other drugs used in combination with fasoracetam can be psychotropic drugs including haloperidol, chlorpromazine, amisulpride, aripiprazole, asenapine, blonanserin, clozapine, iloperidone, lurasidone, melperone, olanzapine, paliperidone, quetiapine, risperidone, sertindole, sulpiride, ziprasidone, or zotepine.

[0100] In some embodiments, fasoracetam can be used in combination with non-pharmacological treatments, such as psychotherapy or brain stimulation therapy. In some embodiments, fasoracetam is used in combination with brain stimulation, which can be vagus nerve stimulation, repetitive transcranial magnetic stimulation, magnetoconvulsive therapy, deep brain stimulation, or any other therapy involving modulation of brain function by electricity, magnets, or implants.

[0101] VII. Manufactured products In some embodiments, the invention includes articles of manufacture that can be used in the methods and treatments described herein. In one embodiment, the article of manufacture is a solid support or microarray for use in detecting genetic alterations in some or all of the mGluR network genes (i.e., Tiers 1-3) listed in Figures 1-3. (See also Tables 1-3 herein, which provide start and end positions for different mGluR network-associated SNPs. This information can be useful in creating microarrays.) In some embodiments, genes included in multiple Tiers are evaluated within the same solid support or microarray. In some embodiments, certain mGluR network genes are excluded. In some embodiments, GRM genes are excluded.

[0102] Thus, for example, in some embodiments where mGluR network genes are assayed to determine whether one or more of the genes have a genetic alteration, such as a CNV, a solid support or microarray, e.g., a chip, is used that contains suitable probes for determining the presence of genetic alterations in 10, 20, 30, 40, 50, 60, 70, or all Tier 1 genes. In certain embodiments, the detectable label is not naturally occurring. In some embodiments, the solid support or microarray may also contain suitable probes for determining the presence of genetic alterations in at least 10, 20, 30, 50, 100, 150, or all Tier 2 genes. In some embodiments, it may further contain suitable probes for determining the presence of genetic alterations in at least 10, 20, 50, 100, 200, 300, 400, 500, or all Tier 3 genes. For example, such solid supports, microarrays or chips can be used to determine the presence of genetic alterations, e.g., CNVs or SNVs, in the Tier 1, Tier 1+2, or Tier 1+2+3 mGluR gene networks as part of a method for treating patients with ADHD or 22q deletions and / or duplications.

[0103] In some embodiments, the product is a probe set for mGluR network genes of interest from Tier 1, 2, and / or 3. In some embodiments, the probes are labeled. Similarly, probe sets can be manufactured to determine the presence of genetic alterations in 10, 20, 30, 40, 50, 60, 70, or all Tier 1 genes. In some embodiments, probes can be manufactured to determine the presence of genetic alterations in at least 10, 20, 30, 50, 100, 150, or all Tier 2 genes. In some embodiments, probes can further include those to determine the presence of genetic alterations in at least 10, 20, 50, 100, 200, 300, 400, 500, or all Tier 3 genes. These various probe sets can be used in methods to determine the presence of genetic alterations, e.g., CNVs or SNVs, in the Tier 1, Tier 1+2, or Tier 1+2+3 mGluR gene network as part of a method of treating patients with ADHD or 22q deletions and / or duplications. [Example]

[0104] Example 1. Enrichment of CNV calls involving mGluR network genes in samples from patients with TS Previously, a large-scale genomic association study (as described in Elia et al., Nature Genetics, 44(1): 78-84 (2012)) of copy number variations abundant in ADHD patients was conducted. Elia's study included approximately 2,493 ADHD patients and approximately 9,222 controls, all of whom were of European descent and between the ages of 6 and 18. The study reported that the rate of CNVs involving mGluR network genes was 1.2% in the control group, and this rate increased to 11.3% in ADHD patients.

[0105] Studies have revealed that rare, recurring CNVs affecting specific mGluR network genes (i.e., GRM1, GRM5, GRM7, and GRM8) encoding metabotropic glutamate receptors (mGluRs) are found at significantly higher frequencies in ADHD patients compared with healthy controls. This large effect size (with odds ratios of >15) suggests that these mutations are likely highly penetrant in their effect on ADHD. Single cases with GRM2 and GRM6 deletions that were not found in controls were also observed. When genes in the mGluR network gene signaling pathway were evaluated, a significant enrichment of CNVs was found within this network in ADHD cases compared with controls.

[0106] We identified a total of 279 mGluR primary network genes based on the merged human interactome provided by Cytoscape software. Network analysis of the mGluR pathway revealed a significant enrichment of CNVs in genes involved in mGluR signaling or their interactors in cases, affecting ∼20% of ADHD cases combined, corrected for control incidence (P = 4.38 × 10-10). These data suggest that mGluR network genes may serve as critical hubs coordinating highly connected modules of interacting genes, many of which may have CNVs and be enriched for synaptic and neuronal biological functions. Therefore, we identified several rare, recurrent CNVs affecting genes involved in glutamatergic neurotransmission that are overrepresented in multiple independent ADHD cohorts.

[0107] TS frequently coexists in children with ADHD. Specifically, approximately two-thirds of children with TS also have ADHD. In addition, as many as 10% of ADHD patients may have tics. Therefore, we investigated whether mGluR gene alterations are also enriched in children with TS.

[0108] The sample for this study was selected based on ICP-9 codes for diagnoses from the electronic health records of children and adolescents treated at Children's Hospital of Philadelphia (CHOP). All 95 subjects were evaluated by a child psychiatrist who entered a diagnosis of TS. All subjects had recurrent tics of sufficient duration to meet the diagnostic criteria for Tourette syndrome. One particular patient in this study had a diagnosis of both schizophrenia and TS.

[0109] CNVs were determined using single nucleotide variant (SNV) / single nucleotide polymorphism (SNP) genotype data. SNV genotyping provides an individual's genetic fingerprint by using a large number of SNV markers to generate high-density SNV genotyping data (see Wang K et al. (Nov 2007) Genome Res. 17(11):1665-74). HumanHap550 Gentyping BeadChip™ (Illumina) or Human610-Quad v1.0 BeadChip™ (Illumina) were used in this study. The same 520 SNVs were analyzed for both chips. Therefore, data from these two chips are interchangeable. Standard manufacturing protocols were used for all genotyping assays. Illumina readers were used for all experiments.

[0110] The SNV genotyping data from each fully genotyped patient sample was analyzed using PennCNV software to determine the signal intensity data and the distribution of SNV allele ratios.These data were then used to determine CNVs by simultaneous analysis of intensity and genotype data (as previously described in Wang 2008).Using this analysis, data showing regions of adjacent SNV loss will result in a CNV deletion call.Data showing regions of adjacent SNV gain will result in a CNV duplication call.A single individual may have multiple CNV deletions / duplications or no CNVs at all.

[0111] As previously discussed, three tiers of mGluR network genes were developed. Figures 1-3 show the genes included in the three gene sets: Tier 1 (76 genes) in Figure 1, Tier 2 (197 genes) in Figure 2, and Tier 3 (599 genes) in Figure 3. Note that these gene sets were non-inclusive, so a single gene was only included in a single tier.

[0112] Figure 4 shows data on the number of CNV calls in each mGluR gene tier for TS patients. CNVs are either duplications or deletions. The data show that a relatively large number of CNV calls were found in each gene set of mGluR network genes in samples from TS patients.

[0113] The percentage of patients with CNV calls (either duplications or deletions) in each gene set of mGluR network genes is shown in Figure 5. Of the 95 children genotyped with TS, 20 (~21%) had mutations in Tier 1 genes (all of which are genes in the mGluR primary network), which we term Tier 1, a gene found to be most significant in ADHD. A total of 28 children, or ~29%, had mutations in all mGluR primary network genes (Tier 1 + 2) evaluated. Approximately 52% of children had mutations in either the primary or secondary (Tier 1 + 2 + 3) mGluR network. This suggests that up to 50% of TS patients may have disrupted this pathway and may be responsive to treatments that reverse the consequences of these mutations.

[0114] These data also show that a substantially higher percentage of TS patients had CNV calls within each of the mGluR network gene sets compared to previously reported frequencies of CNV calls in control populations. The patient control frequency of CNVs in mGluR network genes has previously been estimated to be 1.2% (see Elia), confirming the specificity of the enrichment of mGluR network genes among CNVs in TS patients.

[0115] As shown in Figures 4-5, there was a significant enrichment of mGluR network genes in TS patients. Therefore, diagnostics and treatments focused on modulating the mGluR gene network may be particularly useful in TS patients.

[0116] Example 2. Analysis of mGluR network genes contained within CNVs from TS patient samples Next, we analyzed genotyping data from 95 fully genotyped TS patients to identify genes associated with CNVs.

[0117] Table 1 shows representative CNV data from TS patients in which Tier 1 mGluR network genes were located within or near the CNV in the patient sample. CNVs can result in structural changes that affect the transcription of genes located outside but near the CNV. Therefore, mGluR network genes in Tier 1 of the Tiers located within 500,000 base pairs of the CNV were included in the analysis. If an mGluR network gene is contained within a listed CNV, it is marked with a "distance from gene" value of 0. If an mGluR network gene is not contained within the CNV but is in close proximity to it, it is given a "distance from gene" value greater than 0.

[0118] Table 1 lists the chromosomes on which the CNVs are located, along with their start and end positions relative to Human Genome version 19 (hg19). The number of SNVs (SNPs) located within the CNV is noted as "Num SNPs," and the length of the CNV is noted in base pairs. The Start SNP and End SNP of the CNV are also given.

[0119] The column "State, CN" indicates the copy number resulting from the CNV. Normally, human DNA (i.e., without CNVs) would be diploid and would have a "State, CN" of 2. CNVs with a "State, CN" of 0 or 1 indicate copy number deletions. In contrast, CNVs with a "State, CN" of 3 or greater indicate copy number duplications.

[0120] Confidence values ​​indicate the relative confidence that a CNV call is correct. All CNVs included in this analysis had positive confidence values, indicating a high likelihood that the CNV call is correct. Values ​​of 15 or higher were observed for most CNVs, which is considered very high confidence in the CNV call based on qPCR and Taqman genotyping validation.

[0121] The "mGluR Gene" column in Table 1 lists the specific mGluR network genes within Tier 1 that are included in the listed CNVs. Table 1 is sorted to show all CNVs that include a given Tier 1 mGluR network gene. Some Tier 1 genes may be represented in multiple CNVs from different patients in this study, resulting in multiple rows for those specific mGluR network genes. Some Tier 1 genes may not be represented in CNVs from this particular patient population.

[0122] Table 2 shows data from specific CNVs that included Tier 1 or Tier 2 mGluR network genes. The structure of Table 2 is similar to that of Table 1. The "mGluR Gene" column lists the specific mGluR network genes within Tier 1 or Tier 2 that are included in the listed CNVs. Table 2 is sorted to show all CNVs that included a given Tier 1 or Tier 2 mGluR network gene. Some Tier 1 or Tier 2 genes may be represented in multiple CNVs from different patients in this study, resulting in multiple rows for those particular genes. Some Tier 1 or Tier 2 genes may not be represented in CNVs from this particular patient population.

[0123] Table 3 shows data from specific CNVs that included Tier 1, 2, or 3 mGluR network genes. The structure of Table 3 is similar to that of Tables 1 and 2. The "mGluR Gene" column lists the specific mGluR network genes within Tier 1, Tier 2, or Tier 3 that were included in the listed CNVs. Table 3 is sorted to show all CNVs that included a given Tier 1, 2, or 3 mGluR network gene. Some Tier 1, 2, or 3 genes may be represented in multiple CNVs from different patients in this study, resulting in multiple rows for those specific mGluR network genes. Some Tier 1, 2, or 3 genes may not be represented in CNVs from this particular patient population.

[0124] Taken together, the data in Tables 1-3 show that a wide variety of mGluR network genes contained within each Tier are present in CNVs from TS patients. When larger cohorts of patients with TS are genotyped, all genes within Tiers 1, 2, and 3 show enrichment for CNVs in TS patients.

[0125] Example 3. Treatment of ADHD patients with CNVs in mGluR network genes with fasoracetam monohydrate (NFC-1) and its effect on tic syndrome An open-label, phase Ib clinical trial was conducted to investigate the safety, pharmacokinetics, and efficacy of NFC-1 (fasoracetam monohydrate) in adolescent subjects aged 12 to 17 years, previously diagnosed with ADHD, who also had at least one genetic alteration in an mGluR network gene.

[0126] The study enrolled 30 ADHD subjects between 12 and 17 years of age, of any origin or race, with weights within the 5th and 95th percentiles for their age, and judged to be in otherwise good medical health. Subjects were genotyped and enrolled if they had at least one genetic alteration in the form of at least one copy number variation (deletion or duplication) in an mGluR network gene that potentially disrupts gene function. Seventeen of the 30 subjects had CNVs in tier 1 mGluR network genes, while seven subjects had CNVs in tier 2 genes and six had CNVs in tier 3 genes. At enrollment, several study subjects, including two with recurrent tics, showed evidence of comorbid phenotypes.

[0127] Exclusion criteria included subjects who, in the opinion of the investigator, suffered from any clinically significant mental or physical illness that might confound the results of the study or prevent completion of the study; subjects who were pregnant or breastfeeding; subjects with a history of drug abuse, subjects who tested positive for illicit drugs; subjects who consumed alcoholic beverages; or subjects who otherwise raised concerns with the investigator regarding their compliance or suitability.

[0128] The study included either 50 mg or 200 mg NFC-1 capsules containing fasoracetam monohydrate as the active ingredient, and placebo capsules containing microcellulose. The study design included telephone screening (day 1), a registration period (days 1 to 2), a washout period (days 1-14) for subjects currently receiving ADHD medication, a pharmacokinetic (PK) assessment (day 2), a dose-escalation period (day 35), and a follow-up visit approximately 4 weeks after the last dose, for a maximum of 127 days. All ADHD medications were discontinued during the pre-study washout period. The washout period for stimulants was 2-3 days, and the washout period for atomoxetine or noradrenergic agonists was 10-12 days. No new ADHD medications were initiated during the study.

[0129] After an initial washout period, and PK and initial safety assessments, the dose-escalation phase of the study lasted for 5 weeks. During the first week, all subjects received placebo capsules twice daily. After 1 week of placebo treatment, patients began 1 week of NFC-1 at 50 mg bid. If safety and response data from the previous dose level of fasoracetam were adequate, the subject's dose was increased to the next higher dose (100, 200, or 400 mg). Subjects who tolerated and responded to the 50 mg bid dose were to remain at that level for the remaining 3 weeks of the study.

[0130] Subjects who tolerated but showed a lack of response or partial response to the 50 mg bid dose were to be increased to the next higher 100 mg dose for subsequent weeks. Subjects who tolerated 100 mg but showed a lack of response or partial response were to be increased to the 200 mg dose for subsequent weeks, while subjects who tolerated and responded to 100 mg were to remain on 100 mg bid for the remainder of the study. Similarly, subjects who tolerated and responded to the 200 mg dose were to remain on 200 mg for the final week of the study, while subjects who tolerated but showed a lack of response or partial response were changed to the 400 mg dose for the final week. Of the 30 study subjects, 3 received the maximum dose of 100 mg, 9 received the maximum dose of 200 mg, and the remaining 18 received the maximum dose of 400 mg.

[0131] Although this study was not specifically designed to measure tics or TS, two individuals with a history of recurrent tics did not exhibit tics during treatment with NFC-1.

[0132] Example 4. Treatment of ADHD patients with CNVs in mGluR network genes with fasoracetam monohydrate (NFC-1) and the effect on obsessive-compulsive symptoms Eight of the 30 ADHD subjects studied in the open-label Phase Ib clinical trial described in Example 2 had symptoms of obsessive-compulsive disorder (OCD). One of the tics subjects also had symptoms of OCD. In all eight subjects, OCD symptoms improved during treatment with NFC-1.

[0133] One subject with ODC also had a history of ear-scratching behavior (i.e., self-injurious dermatitis), which led to bleeding ulcers. The bleeding ulcers healed during treatment with NFC-1. This means that the subject's self-injurious dermatitis symptoms were reduced during NFC-1 treatment.

[0134] Example 5. Study of phenotypes associated with mGluR network CNVs A total of 1,000 ADHD patients aged 6-17 years were enrolled in the trial to examine phenotypes potentially associated with CNVs in Tier 1 or 2 mGluR network genes. Saliva samples were collected by the study site. Each DNA sample was then subjected to DNA extraction, gene sequencing, and DNA biobanking.

[0135] Gene sequencing results, along with medical history, were used to assess genotype (based on gene sequencing) and phenotype (based on interviews conducted by clinicians and the subject's parents / guardians). Subjects had ADHD as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V).

[0136] A single clinician asked the parent or patient's legal guardian a series of questions regarding possible behavioral or health phenotypes. For each individual phenotype, the parent / guardian was asked, "Is this a current concern?" and a yes or no response was collected. The clinician determined the frequency of yes or no responses to generate phenotype data.

[0137] This study found that the prevalence of anger control as a current parental concern was 58.9% in ADHD subjects with Tier 1 or 2 mGluR network gene CNVs, but only 47.4% in ADHD subjects without such mGluR network gene CNVs. This difference was statistically significant (odds ratio of 1.59, P=0.003). This odds ratio, greater than 1, implies a higher prevalence of current anger control concerns in ADHD subjects with Tier 1 or 2 mGluR network gene CNVs compared with subjects without such CNVs.

[0138] The prevalence of disruptive behavior as a current patient concern was 57.1% in ADHD subjects with Tier 1 or 2 mGluR network gene CNVs and 43.9% in ADHD subjects without such mGluR network gene CNVs. This difference was also statistically significant (odds ratio of 1.70, P<0.001). This difference indicates a higher prevalence of parental disruptive behavior as a current concern among ADHD subjects who also have mGluR network gene mutations compared with those without mutations.

[0139] Example 6: Copy number variations of mGluR network genes in ADHD subjects with comorbid disorders Samples from 2707 pediatric subjects (mean age 10-10.5 years) known to have ADHD were genotyped using the 550 / 610 Illumina chip to determine whether they had one or more CNVs in Tier 1 or Tier 2 genes. The 2707 subjects included 759 females and 1778 males of African American or Caucasian ethnicity (1063 and 1483, respectively). 430 of the 2707 subjects (16.9%) had at least one CNV in an mGluR Tier 1 or Tier 2 gene.

[0140] The records of the 2707 subjects were also reviewed to determine whether they were diagnosed with comorbidities according to the World Health Organization's International Classification of Diseases, Ninth Revision (ICD-9). Of the 2707 subjects, 1902 (approximately 70%) had comorbidities, while 805 did not. Of these 1902 subjects with comorbidities, approximately 30% had more than one comorbidity, and approximately 20% had two or more, although a small percentage had more comorbidities.

[0141] The most prevalent comorbidities that were present in more than 100 subjects each are listed in Table 4. This table lists the comorbidities by ICD-9 code and provides the number of cases (column titled "N") among the 2707 subjects and the name of each comorbid condition or disorder. TIFF2025183206000002.tif112170

[0142] The comorbidities in Table 4 tend to cluster into a few distinct groups: anxiety, depression, or mood-related disorders; high-prevalence developmental disorders; low-prevalence developmental disorders; and autism and related disorders.

[0143] We then combined the phenotypic and comorbidity data to determine how many subjects with Tier 1 or 2 mGluR network gene CNVs also had comorbidities. We found that 316 of the subjects with such CNVs (approximately 18% of CNV-positive subjects or 12% of all subjects) also had at least one comorbidity, while 114 of the subjects without Tier 1 or 2 mGluR network gene CNVs (approximately 15% of CNV-negative subjects or 4% of all subjects) also had at least one comorbidity. This difference had a P value of 0.118. Thus, overall, comorbidities tended to be more prevalent in CNV-positive subjects than in CNV-negative subjects. When considering only subjects identified as Caucasian, there was a highly significant correlation between mGluR CNVs and ADHD comorbidity. Specifically, 218 of 1483 subjects had at least one CNV in a Tier 1 or 2 mGluR network gene, and of these 218 subjects, 169 also had a comorbidity, while 49 did not. This difference had a P-value of 0.004.

[0144] The foregoing written specification is believed to be sufficient to enable one skilled in the art to practice the embodiments. The foregoing description and examples detail certain particular embodiments and set forth the best mode contemplated by the inventors. However, no matter how detailed the foregoing may appear in the text, it will be understood that the embodiments can be practiced in many ways and should be construed in accordance with the appended claims and any equivalents thereof.

[0145] The term about, as used herein, refers to numerical values, including, for example, integers, fractions, and percentages, whether or not expressly indicated. The term about generally refers to a range of numbers (e.g., + / - 5-10% of the recited range) that one of ordinary skill in the art would consider equivalent to the recited value (e.g., having the same function or result). When terms such as at least and about precede a list of numerical values ​​or ranges, these terms modify all of the values ​​or ranges given in that list. In some cases, the term about may include numerical values ​​rounded to the nearest significant figure. TIFF2025183206000003.tif248170TIFF2025183206000004.tif250170TIFF2025183206000005.tif249170TIFF2025183206000006.tif249170TIFF2025183206000007.tif250170TIFF2025183206000008.tif250170TIFF2025183206000009.tif252170TIFF2025183206000010.tif251170TIFF2025183206000011.tif251170TIFF2025183206000012.tif252170TIFF2025183206000013.tif251170TIFF2025183206000014.tif251170TIFF2025183206000015.tif251170TIFF2025183206000016.tif251170TIFF2025183206000017.tif252170TIFF2025183206000018.tif252170TIFF2025183206000019.tif250170TIFF2025183206000020.tif251170

Claims

1. A method for treating Tourette's syndrome (TS) in a subject, comprising administering to the subject an effective amount of a non-selective activator of metabotropic glutamate receptors (mGluRs), thereby treating TS.

2. 10. The method of claim 1, wherein the subject has at least one genetic alteration in an mGluR network gene.

3. A method for treating TS in a subject, comprising administering an effective amount of a non-selective activator of metabotropic glutamate receptors (mGluRs) to a subject having at least one genetic alteration in an mGluR network gene, thereby treating TS.

4. 1. A method of treating TS in a subject, comprising obtaining results from a genetic screen to determine whether the subject has a genetic alteration in an mGluR network gene, and if the results indicate that the subject has at least one genetic alteration in an mGluR network gene, treating the subject by administering an effective amount of a non-selective activator of mGluR.

5. 5. The method of claim 2, wherein the genetic alteration is a copy number variation (CNV) or a single nucleotide variation (SNV).

6. The method of claim 5 , wherein the genetic alteration is a CNV.

7. The method of claim 6, wherein the CNV is a duplication or deletion.

8. 8. The method of claim 1, wherein the non-selective activator of mGluR is fasoracetam.

9. 9. The method according to claim 8, wherein the fasoracetam is fasoracetam monohydrate (NS-105 or NFC-1).

10. 10. The method of claim 8 or claim 9, wherein fasoracetam is administered in a dose of 50 mg, 100 mg, 150 mg, 200 mg, 250 mg, 300 mg, 350 mg or 400 mg, said dose being administered once, twice or three times daily.

11. 10. The method of claim 8 or claim 9, wherein fasoracetam is administered in a dose of 50-400 mg, 100-400 mg, or 200-400 mg, said dose being administered once, twice, or three times daily.

12. 10. The method of claim 8 or 9, wherein fasoracetam is administered in a dose of 200-400 mg, for example 200 mg, 300 mg or 400 mg, said dose being administered twice daily.

13. 13. The method of any one of claims 1 to 12, wherein the subject has CNVs in at least 2, 3, 4, 5, 6, 7, 8, 9, or 10 mGluR network genes.

14. CNVs in mGluR network genes a. obtaining a nucleic acid-containing sample from said subject and subjecting said sample to a screen that evaluates CNVs in at least 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70 or all Tier 1 mGluR network genes; or b. Obtain a report describing the results of a genetic test that screens for CNVs in at least 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, or all Tier 1 mGluR network genes. The method of any one of claims 5 to 13, wherein the determination is made by:

15. CNVs in mGluR network genes a. obtaining a nucleic acid-containing sample from said subject and subjecting said sample to a screen that evaluates CNVs in at least 50, at least 100, at least 150, at least 175, or all Tier 2 mGluR network genes; or b. Obtain a report describing the results of a genetic test that screened for CNVs in at least 50, at least 100, at least 150, at least 175, or all Tier 2 mGluR network genes. The method of any one of claims 5 to 13, wherein the determination is made by:

16. CNVs in mGluR network genes a. obtaining a nucleic acid sample from the subject and subjecting the sample to a screen that evaluates CNVs in at least 50, at least 100, at least 200, at least 300, at least 400, at least 500, or all Tier 3 mGluR network genes; or b. Obtain a report describing the results of a genetic test that screened for CNVs in at least 50, at least 100, at least 200, at least 300, at least 400, at least 500, or all Tier 3 mGluR network genes. The method of any one of claims 5 to 13, wherein the determination is made by:

17. 17. The method of any one of claims 5 to 16, wherein the screening does not evaluate CNVs of one or more of GRM1, GRM2, GRM3, GRM4, GRM5, GRM6, GRM7 or GRM8.

18. 18. The method of any one of claims 1 to 17, wherein the subject does not have a CNV in one or more of GRM1, GRM2, GRM3, GRM4, GRM5, GRM6, GRM7, or GRM8.

19. 19. The method of any one of claims 1 to 18, wherein the TS is one or more of persistent (chronic) motor tic disorder, persistent (chronic) vocal tic disorder, or provisional tic disorder.

20. 20. The method of any one of claims 1 to 19, wherein the subject is a pediatric subject.

21. 21. The method of claim 20, wherein the pediatric patient is an adolescent.

22. 21. The method of claim 20, wherein the pediatric subject is between 5 and 17 years old, between 5 and 8 years old, between 8 and 17 years old, between 8 and 12 years old, or between 12 and 17 years old.

23. 20. The method of any one of claims 1 to 19, wherein the subject is an adult.

24. 24. The method of any one of claims 1 to 23, wherein the non-selective activator of mGluRs is administered in combination with another drug or non-drug therapy.

25. 25. The method of claim 24, wherein the non-drug therapy comprises brain stimulation, such as vagus nerve stimulation, repetitive transcranial magnetic stimulation, magnetoconvulsive therapy, or deep brain stimulation.

26. 26. The method of claim 24 or 25, wherein the activator is administered in combination with an antipsychotic agent.

27. 27. The method of any one of claims 1 to 26, wherein tic symptoms are reduced in a subject after at least 1 week, such as at least 2 weeks, such as at least 3 weeks, such as at least 4 weeks of treatment with the activator.

28. 28. The method of claim 27, wherein the tic symptoms include frequency and / or severity of movements.

29. 29. The method of any one of claims 1 to 28, wherein symptoms of inattention, hyperactivity and / or impulsivity are reduced in a subject after at least 1 week, such as at least 2 weeks, such as at least 3 weeks, such as at least 4 weeks of treatment with the activator.

30. 21. The method of any one of claims 1 to 20, wherein the subject also has obsessive-compulsive disorder (OCD).

31. 31. The method of any one of claims 1 to 30, wherein the symptoms of obsessive-compulsive disorder (OCD) are reduced in the subject after at least 1 week, such as at least 2 weeks, such as at least 3 weeks, such as at least 4 weeks of treatment with the activator.

32. 1. A method for diagnosing TS in a subject, comprising: a. isolating a sample containing nucleic acid from a subject; b. analyzing the sample for the presence or absence of a genetic alteration in at least one mGluR network gene; and c. Diagnosing TS if the subject has at least one genetic alteration in an mGluR network gene. A method comprising:

33. 1. A method for diagnosing TS in a subject, comprising: a. obtaining the results of a genetic test in which the subject is screened for the presence or absence of a genetic alteration in at least one mGluR network gene; and b. diagnosing TS if the results indicate that the subject has at least one genetic alteration in an mGluR network gene. A method comprising:

34. 1. A method for identifying a subject as having TS, comprising obtaining a sample from a patient, optionally isolating nucleic acid from said sample, optionally amplifying said nucleic acid, and analyzing said nucleic acid in said sample for the presence or absence of at least one mGluR network genetic alteration, e.g., CNV, wherein if at least one genetic alteration, e.g., CNV, in an mGluR network gene is detected, said subject is identified as having TS.

35. 1. A method for diagnosing TS in a subject, the method comprising: analyzing genetic information for one or more mGluR network genes; optionally comparing the subject's information with a control subject without TS; and diagnosing TS if the genetic information suggests that the subject has at least one genetic alteration in an mGluR network gene.

36. 1. A method of confirming a diagnosis of TS in a subject, comprising: a. Obtaining a sample containing nucleic acid from a subject diagnosed with TS by a method that does not involve detecting or analyzing genetic alterations in mGluR network genes; b. optionally amplifying the nucleic acid in the sample; and c. Determining whether the subject has at least one genetic alteration, e.g., CNV, in an mGluR network gene, and confirming the diagnosis of TS if the subject has at least one genetic alteration in an mGluR network gene. A method comprising:

37. 37. The method of any one of claims 32 to 36, wherein the analysis of mGluR network genes for the presence or absence of at least one genetic alteration comprises the use of microarray, whole genome sequencing, exome sequencing, targeted sequencing, FISH, comparative genomic hybridization, genome mapping, or other methods using next generation sequencing, Sanger sequencing, PCR, or TaqMan technology.

38. 38. The method of any one of claims 32 to 37, wherein the subject has CNVs in at least two mGluR network genes.

39. 39. The method of any one of claims 32 to 38, comprising detecting CNV in mGluR network genes by subjecting the sample to a screen that assesses CNV in at least 2, 3, 4, 5, 6, 7, 8, 9 or 10 mGluR network genes.

40. 40. The method of any one of claims 32 to 39, wherein CNV in mGluR network genes is determined by subjecting the sample to a screen that assesses CNV in at least 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70 or all Tier 1 mGluR network genes.

41. 41. The method of any one of claims 32 to 40, wherein CNVs in mGluR network genes are determined by subjecting the sample to a screen that evaluates CNVs in at least 50, at least 100, at least 150, at least 175, or all Tier 2 mGluR network genes.

42. 42. The method of any one of claims 32 to 41, wherein CNVs in mGluR network genes are determined by subjecting the sample to a screen that evaluates CNVs in at least 50, at least 100, at least 200, at least 300, at least 400, at least 500, or all Tier 3 mGluR network genes.

43. 43. The method of any one of claims 32 to 42, wherein the TS is one or more of persistent (chronic) motor tic disorder, persistent (chronic) vocal tic disorder, or provisional tic disorder.

44. 44. The method of any one of claims 32 to 43, wherein the subject is a pediatric subject.

45. 45. The method of claim 44, wherein the pediatric subject is between 5 and 17 years of age, between 5 and 8 years of age, between 8 and 17 years of age, between 8 and 12 years of age, or between 12 and 17 years of age.

46. 46. ​​The method of claim 45, wherein the subject is an adolescent.

47. 44. The method of any one of claims 32 to 43, wherein the subject is an adult subject.

48. 48. The method of any one of claims 32 to 47, wherein the subject is not evaluated for genetic alterations or CNVs in one or more of GRM1, GRM2, GRM3, GRM4, GRM5, GRM6, GRM7 and GRM8.

49. 48. The method of any one of claims 32 to 47, wherein the method for determining the presence or absence of at least one genetic alteration in an mGluR network gene comprises the use of microarray, whole genome sequencing, exome sequencing, targeted sequencing, FISH, comparative genomic hybridization, genome mapping, or other methods using next generation sequencing, Sanger sequencing, PCR, or TaqMan technology.

50. 50. The method of any one of claims 32 to 49, wherein the subject is not evaluated for CNV of one or more of GRM1, GRM2, GRM3, GRM4, GRM5, GRM6, GRM7 and GRM8.

51. 51. The method of any one of claims 1 to 50, wherein the subject has TS and schizophrenia.

52. 52. The method of any one of claims 1 to 51, wherein the subject has TS and ADHD.

53. 53. The method of any one of claims 1 to 52, wherein the subject has TS and obsessive-compulsive disorder (OCD).

54. 53. The method of any one of claims 1 to 52, wherein the subject does not have one or more of ADHD, schizophrenia, conduct disorder, anxiety disorder, autism, mood disorder, phobia, OCD, or depression.

55. Use of an mGluR activator in the preparation of a medicament for treating TS and / or OCD.

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