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Contact details or Visit your trusted travel agent and ask for TIC information Which policy will suit you best? Consider these six points when choosing a product best suited for your requirements: What type of travel are you undertaking?

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Facts that can impact on the type of cover to choose: Are you performing manual labour? Then consider the Business Industrial Policy. If you are not performing manual labour, consider the Business Administrative Policy 2. For leisure travel, define what type of cover you need. Consider the Leisure Comprehensive Policy if: As a family with children sharing cover, you are travelling to a country with a high exchange rate You are away for a long period of time. The longer the journey, the greater the risk of an incident or accident You require higher limits to protect yourself when cancelling or curtailing your journey You want to make absolutely sure that you have the best cover that TIC has to offer Consider the Leisure Standard Policy if: Quality of life is significantly impaired in a substantial number of patients not only due to tics and comorbidities but also because of ignorance and a lack of information, leading to bullying and stigmatization.

Thus, TS poses a considerable burden not only to patients but also to health-care providers. For many years, dopamine receptor antagonists have been recommended as first choice treatment for tics, although these drugs are often associated with significant adverse effects. In Germany and several other countries, however, only haloperidol is officially licensed for the treatment of TS 5. Therefore, a large number of other substances including clonidine, tetrabenazine, dopamine agonists, botulinum toxin, and cannabinoids has been suggested for the treatment of tics.

However, for most of these medications evidence is limited. Data of two large recently conducted and well-powered randomized controlled trials RCT — including more than patients each — confirmed preliminary results and demonstrated that behavioral therapy with Comprehensive Behavioral Intervention for Tics CBIT is an effective and safe treatment for managing the tics of children and adults with TS 6 , 7. Its effectiveness in conjunction with the lack of side effects are clear benefits of CBIT, and are advantages over currently used medications, offering thus a competitive alternative for treating tic disorders.

However in Germany and most other European countries, this recommendation cannot be implemented, since there is a considerable lack of psychotherapists trained in CBIT. Motivated by these significant barriers to dissemination, a recent study compared the effect of face-to-face to video-delivered CBIT demonstrating comparable efficacy and acceptability However, while video-delivered CBIT — compared to face-to-face CBIT — is independent of the location, it is still dependent on the availability of well-trained therapists conducting the video sessions.

Unfortunately, this is not the case in many European countries, including Germany, where therapists trained and experienced in CBIT are lacking on a national scale. As of today, there is even no therapy manual or patient workbook available for the treatment of adult patients with TS in German language. In other psychiatric conditions such as depression 12 , 13 and anxiety disorders 14 , Internet-delivered self-guided psychotherapy using cognitive behavioral therapy, interpersonal psychotherapy and psychodynamic treatment has been shown to be superior to a control condition and comparably effective as face-to-face psychotherapy Due to the simple nature of the exercises involved in CBIT, we have reason to assume that CBIT is particularly well suited to be delivered via Internet compared to those more complex psychotherapeutic interventions.

Although interventions via video, Skype, or smartphone have been suggested 11 , 17 , 18 and, in addition, an RCT started only recently testing the efficacy of a computerized, self-administered version of CBIT called http: Since in TS — due to the natural waxing and waning course of tics — it is difficult to demonstrate efficacy of a treatment, only a well-designed and sufficiently powered study is suitable to demonstrate efficacy.

Therefore, our study will be a multicenter, prospective, controlled, randomized, observer-blind clinical trial that aims to include patients. It is designed to examine the efficacy of an iCBIT intervention as compared to 1 a placebo platform consisting of psychoeducation only — which is our primary analysis — and 2 a conventional face-to-face CBIT intervention — which is our secondary analysis. We hypothesize that iCBIT 1 is superior to the placebo platform and 2 has a comparable effect size to the face-to-face treatment arm.

Moreover, further advertisement will be carried out by German self-help and advocacy groups, newsletters, and annual meetings.

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Patients who are interested in participation will be referred to the study centers, where they will be informed about the details of the study and an appointment for a screening visit will be made. During screening, patients will be informed orally and in writing about clinical assessments and randomized allocation.

There will be no financial compensation for the study participation. However, travel costs will be reimbursed. Before being enrolled, patients will have to provide written consent. This is a multicenter, prospective, randomized, controlled, observer-blind clinical trial on the efficacy of iCBIT in the treatment of tics in adult patients with TS or other chronic tic disorders. For four of the five planned study sites except for Hanover , a two-armed study design will be used — consisting of a placebo-treatment arm Internet-based psychoeducation and an iCBIT-treatment arm.

Hannover is the only center offering the face-to-face treatment due to the lack of well-trained therapists in Germany even in centers specializing in TS. This study is registered on ClinicalTrials. These broad inclusion and exclusion criteria were based on the study by Wilhelm et al. Potential bias will be minimized by randomized treatment allocation. There will be a 1: The randomization will be conducted centrally via web randomization.

Patients will be given a sealed envelope by the investigator containing the access code for the therapy platform or — only at the MHH center — information for face-to-face CBIT. The study is observer blind.

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Although the patients will receive no information as to which treatment arm they are assigned to, it can be assumed that patients will find out. This will definitely be the case in the face-to-face CBIT treatment arm, but will most likely happen in the iCBIT — and placebo treatment arms as well, since all patients will be informed about the study objectives and the contents of the possible treatment arms.

Introduction

Thus, a genuine blinding of patients will not be possible. This represents a fundamental problem in all studies with psychotherapeutic interventions. However, much effort is being put into avoiding the unblinding of study physicians:. In order to ensure that the patients will take active part in the Internet-based intervention, several automated checkups are integrated into the online platform for two purposes: Second, a direct quantification of the compliance is possible after study completion and compliance can be analyzed statistically.

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To all patients randomized to the placebo platform, an open, uncontrolled participation in the iCBIT therapy will be offered after study completion. However, this will only be possible for those patients in the face-to-face CBIT and the placebo treatment arms, who have been compliant before and completed the randomized treatment. HRT, the primary component of CBIT, is based on the premise that tics are maintained by response chaining, lack of awareness of their occurrence, excessive practice, social reinforcement, and tolerance of the tics The core element of HRT, in turn, is CRT that aims to introduce a voluntarily performed non-tic movement that is physically incompatible with the performance of the tic.

Thus, the competing response encourages the subject to respond to the urge by performing a movement competing with the tic. Over time, performance of the competing response breaks the cycle between the premonitory urge and the relief following the tic. It is following the manual for face-to-face CBIT by Woods 20 with respect to both, number and content of treatment sessions, distribution of CBIT elements to particular treatment sessions, and duration of treatment.

Thus, the only difference between this conventional and well established form of CBIT and iCBIT will be the route of delivery, on the one hand via face-to-face and on the other hand via Internet. Only very few adaptations have been inevitable due to Internet-delivery such as more extensive psychoeducation, description of CBIT at great length and inclusion of additional contents.

Additional content will be offered in form of a FAQ section, which is meant to provide answers to most frequent questions that might arise over the course of the program. Working sheets can either be used online or can be printed out for use in paper form.

A part of the working materials can alternatively be used via smartphone app. The control group will consist of psychoeducation only. Patients in the control group will receive no elements of CBIT. Psychoeducation will include additional disorder-specific information. Due to the well-known disadvantages of waiting list designs, we decided against using it in our study This additional treatment arm will only be offered in Hanover.

In addition, each face-to-face session will correspond exactly to the iCBIT sessions: In the period of time from the end of active treatment until the last follow-up visit see below , patients in all treatment arms will get the option of receiving booster sessions to refresh the therapy. There will be no limitation in terms of number, scope, and duration of these additional sessions in the Internet-based treatment arms. In these sessions, patients will have access to information earlier provided in the eight sessions of their treatment module.

However, no new information or contents will be offered. The technical implementation of the Internet-based treatment is being set in place in cooperation with the Minddistrict company. All treatment-related contents for the online modules are being developed by the research team at the MHH. In the final stage of development, the platform will be reviewed by the authors of the original CBIT manual Douglas Woods and Sabine Wilhelm who is a German native speaker.

Prior to study begin, the platform will be additionally pilot tested by a small group of patients with tic disorders to verify its practicability and usability. Feedback will be used for further optimization of the platform before study launch. This has also been used in studies demonstrating efficacy of face-to-face CBIT 6 , 7.

The following further secondary outcome measures will be included: Thus, time points of assessment in this study are comparable to those in the study by Wilhelm et al. Randomization will be performed at the baseline visit. At week 17 and 29 1. These additional visits serve the purpose of improving compliance in order to keep the drop-out rate as low as possible. During these telephone visits there will be no further testing. Frequency, scope, and number will vary individually in the iCBIT and placebo groups, in the face-to -face CBIT group up to two booster sessions a min between week 11 and 35 are possible.

In the face-to-face CBIT treatment, arm compliance will also be determined via regular and full participation in the therapy sessions. In the iCBIT and placebo groups, the participation in the therapy session will be determined automatically by the online platform by collecting information on when, how long and where the patients were logged in.

The sample size calculation is based on two studies in which the efficacy of face-to-face CBIT was compared with face-to-face psychoeducation in adult and pediatric patients with TS and chronic tic disorders 6 , 7.

However, we expect a mean difference of 3. Under these conditions and with a one-sided type I error of 2. Therefore, a total of patients will be included in the Internet-based treatment arms iCBIT and placebo. Sixteen patients will be randomized to face-to-face CBIT. The study is not powered for this secondary non-inferiority analysis.

The primary analysis will be performed in the intention-to-treat population. The patient variable will be considered a random effect. Superiority of iCBIT will be shown if the upper limit of this confidence interval is less than 0. If your opponent does not take the center square, you are most certainly assured to win! Place your second X in the center square to force your opponent to block you.

Then place your third X in one of the border squares and next to the square where you made your first move. By doing this, you have a double winning move and your opponent will only be able to block one of them. Giving you the victory! When your opponent follows by choosing the center square as their first move, you may still have a chance of winning if your opponent makes an error later in the game.

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Otherwise, a perfect series of moves by each player will end in a draw. Each player's position will be X-O-X. If your opponent takes one of the other corner squares, you can be sure to win. Play the last corner available and you will have a double chance for victory!

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