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Guidry BS, Tang AR, Thomas H, Thakkar R, Sermarini A, Dambrino RJ, Yengo-Kahn A, Chambless LB, Morone P, Chotai S. Loss to Follow-Up and Unplanned Readmission After Emergent Surgery for Acute Subdural Hematoma. Neurosurgery 2022; 91:399-405. [DOI: 10.1227/neu.0000000000002053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 04/03/2022] [Indexed: 11/18/2022] Open
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Swearing and coprophenomena - A multidimensional approach. Neurosci Biobehav Rev 2021; 126:12-22. [PMID: 33757814 DOI: 10.1016/j.neubiorev.2021.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
Swearing, cursing, expletives - all these terms are used to describe the utterance of taboo words. Studies show that swearing makes up around 0.5 % of the daily spoken content, however, the inter-individual variability is very high. One kind of pathologic swearing is coprolalia in Tourette syndrome (TS), which describes the involuntary outburst of taboo words. Coprolalia occurs in approximately 20-30 % of all patients with TS. This review compares swearing in healthy people and coprolalia in people with TS and is the first one to develop a multidimensional framework to account for both phenomena from a similar perspective. Different research findings are embedded in one theoretical framework consisting of reasons, targets, functions/effects and influencing factors for swearing and coprolalia. Furthermore, the very limited research investigating obscene gestures and copropraxia, compulsive obscene gestures, is summarized. New research questions and gaps are brought up for swearing, obscene gestures and coprophenomena.
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Prevalence and clinical correlates of self-injurious behavior in Tourette syndrome. Neurosci Biobehav Rev 2020; 113:299-307. [DOI: 10.1016/j.neubiorev.2020.03.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/11/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
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Mufford M, Cheung J, Jahanshad N, van der Merwe C, Ding L, Groenewold N, Koen N, Chimusa ER, Dalvie S, Ramesar R, Knowles JA, Lochner C, Hibar DP, Paschou P, van den Heuvel OA, Medland SE, Scharf JM, Mathews CA, Thompson PM, Stein DJ. Concordance of genetic variation that increases risk for tourette syndrome and that influences its underlying neurocircuitry. Transl Psychiatry 2019; 9:120. [PMID: 30902966 PMCID: PMC6430767 DOI: 10.1038/s41398-019-0452-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 02/13/2019] [Accepted: 02/16/2019] [Indexed: 01/18/2023] Open
Abstract
There have been considerable recent advances in understanding the genetic architecture of Tourette syndrome (TS) as well as its underlying neurocircuitry. However, the mechanisms by which genetic variation that increases risk for TS-and its main symptom dimensions-influence relevant brain regions are poorly understood. Here we undertook a genome-wide investigation of the overlap between TS genetic risk and genetic influences on the volume of specific subcortical brain structures that have been implicated in TS. We obtained summary statistics for the most recent TS genome-wide association study (GWAS) from the TS Psychiatric Genomics Consortium Working Group (4644 cases and 8695 controls) and GWAS of subcortical volumes from the ENIGMA consortium (30,717 individuals). We also undertook analyses using GWAS summary statistics of key symptom factors in TS, namely social disinhibition and symmetry behaviour. SNP effect concordance analysis (SECA) was used to examine genetic pleiotropy-the same SNP affecting two traits-and concordance-the agreement in single nucelotide polymorphism (SNP) effect directions across these two traits. In addition, a conditional false discovery rate (FDR) analysis was performed, conditioning the TS risk variants on each of the seven subcortical and the intracranial brain volume GWAS. Linkage disequilibrium score regression (LDSR) was used as validation of the SECA method. SECA revealed significant pleiotropy between TS and putamen (p = 2 × 10-4) and caudate (p = 4 × 10-4) volumes, independent of direction of effect, and significant concordance between TS and lower thalamic volume (p = 1 × 10-3). LDSR lent additional support for the association between TS and thalamus volume (p = 5.85 × 10-2). Furthermore, SECA revealed significant evidence of concordance between the social disinhibition symptom dimension and lower thalamus volume (p = 1 × 10-3), as well as concordance between symmetry behaviour and greater putamen volume (p = 7 × 10-4). Conditional FDR analysis further revealed novel variants significantly associated with TS (p < 8 × 10-7) when conditioning on intracranial (rs2708146, q = 0.046; and rs72853320, q = 0.035) and hippocampal (rs1922786, q = 0.001) volumes, respectively. These data indicate concordance for genetic variation involved in disorder risk and subcortical brain volumes in TS. Further work with larger samples is needed to fully delineate the genetic architecture of these disorders and their underlying neurocircuitry.
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Affiliation(s)
- Mary Mufford
- 0000 0004 1937 1151grid.7836.aHuman Genetics Research Unit, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Josh Cheung
- 0000 0001 2156 6853grid.42505.36Imaging Genetics Center, Mark and Mary Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of the University of Southern California, Los Angeles, CA USA
| | - Neda Jahanshad
- 0000 0001 2156 6853grid.42505.36Imaging Genetics Center, Mark and Mary Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of the University of Southern California, Los Angeles, CA USA
| | - Celia van der Merwe
- 0000 0004 1937 1151grid.7836.aHuman Genetics Research Unit, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Linda Ding
- 0000 0001 2156 6853grid.42505.36Imaging Genetics Center, Mark and Mary Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of the University of Southern California, Los Angeles, CA USA
| | - Nynke Groenewold
- 0000 0004 1937 1151grid.7836.aDepartment of Psychiatry and MRC Unit on Risk & Resilience, University of Cape Town, Cape Town, South Africa
| | - Nastassja Koen
- 0000 0004 1937 1151grid.7836.aDepartment of Psychiatry and MRC Unit on Risk & Resilience, University of Cape Town, Cape Town, South Africa ,0000 0004 0635 1506grid.413335.3Groote Schuur Hospital and Neuroscience Institute, Cape Town, South Africa
| | - Emile R. Chimusa
- 0000 0004 1937 1151grid.7836.aHuman Genetics Research Unit, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Shareefa Dalvie
- 0000 0004 1937 1151grid.7836.aDepartment of Psychiatry and MRC Unit on Risk & Resilience, University of Cape Town, Cape Town, South Africa ,0000 0004 0635 1506grid.413335.3Groote Schuur Hospital and Neuroscience Institute, Cape Town, South Africa
| | - Raj Ramesar
- 0000 0004 1937 1151grid.7836.aHuman Genetics Research Unit, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - James A. Knowles
- 0000 0001 2156 6853grid.42505.36Department of Psychiatry and the Behavioural Sciences, Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | - Christine Lochner
- 0000 0001 2214 904Xgrid.11956.3aDepartment of Psychiatry, University of Stellenbosch, Stellenbosch, South Africa
| | - Derrek P. Hibar
- 0000 0001 2156 6853grid.42505.36Imaging Genetics Center, Mark and Mary Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of the University of Southern California, Los Angeles, CA USA
| | - Peristera Paschou
- 0000 0004 1937 2197grid.169077.eDepartment of Biological Sciences, Purdue University, West Lafayette, IN USA
| | - Odile A. van den Heuvel
- grid.484519.5Department of Psychiatry, Department of Anatomy & Neurosciences, VU University Medical Center, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Sarah E. Medland
- 0000 0001 2294 1395grid.1049.cQIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Jeremiah M. Scharf
- 000000041936754Xgrid.38142.3cPsychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Harvard Medical School, Boston, MA USA ,0000 0004 0386 9924grid.32224.35Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA ,0000 0004 0386 9924grid.32224.35Department of Neurology, Massachusetts General Hospital, Boston, MA USA
| | - Carol A. Mathews
- 0000 0004 1936 8091grid.15276.37Department of Psychiatry, Genetics Institute, University of Florida, Gainesville, FL USA
| | - Paul M. Thompson
- 0000 0001 2156 6853grid.42505.36Imaging Genetics Center, Mark and Mary Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of the University of Southern California, Los Angeles, CA USA
| | - Dan J. Stein
- 0000 0004 1937 1151grid.7836.aDepartment of Psychiatry and MRC Unit on Risk & Resilience, University of Cape Town, Cape Town, South Africa ,0000 0004 0635 1506grid.413335.3Groote Schuur Hospital and Neuroscience Institute, Cape Town, South Africa
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Cravedi E, Deniau E, Giannitelli M, Pellerin H, Czernecki V, Priou T, Xavier J, Consoli A, Hartmann A, Cohen D. Disentangling Tourette syndrome heterogeneity through hierarchical ascendant clustering. Dev Med Child Neurol 2018; 60:942-950. [PMID: 29748952 DOI: 10.1111/dmcn.13913] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2018] [Indexed: 11/28/2022]
Abstract
AIM To explore the heterogeneity of Tourette syndrome as part of a neurodevelopmental spectrum. METHOD Using hierarchical ascendant clustering based on tic symptoms, developmental milestones, and neurodevelopmental comorbidities, we analyzed the heterogeneity of Tourette syndrome phenotypes in a sample of 174 children and adolescents with Tourette syndrome referred to a tertiary university clinic. RESULTS The model yielded three distinct clusters characterized as follows. In cluster 1, we found many neurodevelopmental comorbidities (including intellectual disabilities, autism spectrum disorder, attention-deficit-hyperactivity disorder [ADHD], and learning disabilities) and academic impairments. In cluster 2, patients had no other neurodevelopmental comorbidities. In cluster 3, patients had higher intelligence, a high frequency of attentional impairment, school problems related to both ADHD and unspecific attention difficulties, and handwriting problems related to the tics themselves. Interestingly, clusters did not differ in terms of family history or anxious-depressive comorbidities. The only other differences that emerged were related to prenatal or perinatal risk factors (more represented in cluster 1) and treatment profiles (higher rates of stimulants in cluster 1). INTERPRETATION We conclude that from a phenotypical perspective, Tourette syndrome is a heterogeneous syndrome with at least three main clusters that may help in addressing the etiological basis of Tourette syndrome and specific rehabilitative and therapeutic approaches. WHAT THIS PAPER ADDS The clustering of Tourette syndrome based on comorbidity with other neurodevelopmental conditions reveals three clusters. A group of patients with Tourette syndrome show school difficulties related to non-specific attention and writing problems. Analysing only children and adolescents helps to distinguish between developmental comorbid conditions and coexistent disorders.
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Affiliation(s)
- Elena Cravedi
- Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, Paris, France.,Pediatric Neurology Unit, Children's Hospital A. Meyer, University of Firenze, Firenze, Italy
| | - Emmanuelle Deniau
- Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, Paris, France.,Department of Neurology, National Reference Centre for Tourette Syndrome, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Marianna Giannitelli
- Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Hugues Pellerin
- Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Virginie Czernecki
- Department of Neurology, National Reference Centre for Tourette Syndrome, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Tiphanie Priou
- Department of Neurology, National Reference Centre for Tourette Syndrome, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Jean Xavier
- Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Angèle Consoli
- Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Andreas Hartmann
- Department of Neurology, National Reference Centre for Tourette Syndrome, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - David Cohen
- Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, Paris, France.,Institute for Intelligent Systems and Robotics, UPMC, Sorbonne Université, Paris, France
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Hirschtritt ME, Darrow SM, Illmann C, Osiecki L, Grados M, Sandor P, Dion Y, King RA, Pauls D, Budman CL, Cath DC, Greenberg E, Lyon GJ, Yu D, McGrath LM, McMahon WM, Lee PC, Delucchi KL, Scharf JM, Mathews CA. Genetic and phenotypic overlap of specific obsessive-compulsive and attention-deficit/hyperactive subtypes with Tourette syndrome. Psychol Med 2018; 48:279-293. [PMID: 28651666 PMCID: PMC7909616 DOI: 10.1017/s0033291717001672] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The unique phenotypic and genetic aspects of obsessive-compulsive (OCD) and attention-deficit/hyperactivity disorder (ADHD) among individuals with Tourette syndrome (TS) are not well characterized. Here, we examine symptom patterns and heritability of OCD and ADHD in TS families. METHOD OCD and ADHD symptom patterns were examined in TS patients and their family members (N = 3494) using exploratory factor analyses (EFA) for OCD and ADHD symptoms separately, followed by latent class analyses (LCA) of the resulting OCD and ADHD factor sum scores jointly; heritability and clinical relevance of the resulting factors and classes were assessed. RESULTS EFA yielded a 2-factor model for ADHD and an 8-factor model for OCD. Both ADHD factors (inattentive and hyperactive/impulsive symptoms) were genetically related to TS, ADHD, and OCD. The doubts, contamination, need for sameness, and superstitions factors were genetically related to OCD, but not ADHD or TS; symmetry/exactness and fear-of-harm were associated with TS and OCD while hoarding was associated with ADHD and OCD. In contrast, aggressive urges were genetically associated with TS, OCD, and ADHD. LCA revealed a three-class solution: few OCD/ADHD symptoms (LC1), OCD & ADHD symptoms (LC2), and symmetry/exactness, hoarding, and ADHD symptoms (LC3). LC2 had the highest psychiatric comorbidity rates (⩾50% for all disorders). CONCLUSIONS Symmetry/exactness, aggressive urges, fear-of-harm, and hoarding show complex genetic relationships with TS, OCD, and ADHD, and, rather than being specific subtypes of OCD, transcend traditional diagnostic boundaries, perhaps representing an underlying vulnerability (e.g. failure of top-down cognitive control) common to all three disorders.
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Affiliation(s)
| | - Sabrina M. Darrow
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Cornelia Illmann
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Osiecki
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Grados
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul Sandor
- Department of Psychiatry, University of Toronto and University Health Network, Youthdale Treatment Centers, Toronto, Ontario, Canada
| | - Yves Dion
- Department of Psychiatry, University of Montreal, Montreal, Quebec, Canada
| | - Robert A. King
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA
| | - David Pauls
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cathy L. Budman
- Department of Psychiatry, North Shore University Hospital, Northwell Health System, Manhasset, NY, USA
| | - Danielle C. Cath
- Faculty of Social and Behavioural Sciences, Utrecht University and Altrecht Academic Anxiety Center, Utrecht, GGz Drenthe and department of psychiatry, University Medical Center Groningen, The Netherlands
| | - Erica Greenberg
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gholson J. Lyon
- Stanley Institute for Cognitive Genomics, Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA
| | - Dongmei Yu
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Paul C. Lee
- Department of Behavioral Health, Tripler Army Medical Center, Honolulu, HI, USA
| | - Kevin L. Delucchi
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Jeremiah M. Scharf
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Cognitive and Behavioral Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Carol A. Mathews
- Department of Psychiatry, and University of Florida Genetics Institute, University of Florida, Gainesville, FL, USA
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Cravedi E, Deniau E, Giannitelli M, Xavier J, Hartmann A, Cohen D. Tourette syndrome and other neurodevelopmental disorders: a comprehensive review. Child Adolesc Psychiatry Ment Health 2017; 11:59. [PMID: 29225671 PMCID: PMC5715991 DOI: 10.1186/s13034-017-0196-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 11/21/2017] [Indexed: 12/14/2022] Open
Abstract
Gilles de la Tourette syndrome (TS) is a complex developmental neuropsychiatric condition in which motor manifestations are often accompanied by comorbid conditions that impact the patient's quality of life. In the DSM-5, TS belongs to the "neurodevelopmental disorders" group, together with other neurodevelopmental conditions, frequently co-occurring. In this study, we searched the PubMed database using a combination of keywords associating TS and all neurodevelopmental diagnoses. From 1009 original reports, we identified 36 studies addressing TS and neurodevelopmental comorbidities. The available evidence suggests the following: (1) neurodevelopmental comorbidities in TS are the rule, rather than the exception; (2) attention deficit/hyperactivity disorder (ADHD) is the most frequent; (3) there is a continuum from a simple (TS + ADHD or/and learning disorder) to a more complex phenotype (TS + autism spectrum disorder). We conclude that a prompt diagnosis and a detailed description of TS comorbidities are necessary not only to understand the aetiological basis of neurodevelopmental disorders but also to address specific rehabilitative and therapeutic approaches.
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Affiliation(s)
- Elena Cravedi
- 0000 0001 2150 9058grid.411439.aDepartment of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, 83, boulevard de l’hôpital, 75013 Paris, France ,0000 0004 1757 2304grid.8404.8Pediatric Neurology Unit, Children’s Hospital A. Meyer, University of Firenze, Florence, Italy
| | - Emmanuelle Deniau
- 0000 0001 2150 9058grid.411439.aDepartment of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, 83, boulevard de l’hôpital, 75013 Paris, France ,0000 0001 2150 9058grid.411439.aDepartment of Neurology, Reference Centre for Tourette Syndrome, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Marianna Giannitelli
- 0000 0001 2150 9058grid.411439.aDepartment of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, 83, boulevard de l’hôpital, 75013 Paris, France
| | - Jean Xavier
- 0000 0001 2150 9058grid.411439.aDepartment of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, 83, boulevard de l’hôpital, 75013 Paris, France
| | - Andreas Hartmann
- 0000 0001 2150 9058grid.411439.aDepartment of Neurology, Reference Centre for Tourette Syndrome, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - David Cohen
- 0000 0001 2150 9058grid.411439.aDepartment of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, APHP, 83, boulevard de l’hôpital, 75013 Paris, France ,0000 0001 1955 3500grid.5805.8CNRS UMR 7222, Institute for Intelligent Systems and Robotics, Sorbonnes Universités, UPMC, Paris, France
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Groth C, Debes NM, Skov L. Phenotype Development in Adolescents With Tourette Syndrome: A Large Clinical Longitudinal Study. J Child Neurol 2017; 32:1047-1057. [PMID: 29046136 DOI: 10.1177/0883073817729917] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Tourette syndrome (TS) is a neurodevelopmental disorder characterized by frequent comorbidities and a wide spectrum of phenotype presentations. This study aimed to describe the development of phenotypes in TS and tic-related impairment in a large longitudinal study of 226 children and adolescents followed up after 6 years. The participants were clinically examined to assess tic severity and impairment, obsessive compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD). The development in phenotypes changed toward less comorbidity with 40% TS-only (no OCD or ADHD) (TS without OCD or ADHD) at baseline and 55% at follow-up.Tic-related impairment was expected to improve with an age-related tic decline, but surprisingly the impairment score did not reflect the tic decline. Sex, vocal and motor tics, and OCD and ADHD severity were highly significantly correlated to the impairment score. Knowledge of TS phenotype development is used in clinical settings to guide patients and for genetic, etiological, and clinical research purposes.
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Affiliation(s)
- Camilla Groth
- 1 Department of Paediatrics, Copenhagen University Hospital, Herlev, Denmark
| | - Nanette Mol Debes
- 1 Department of Paediatrics, Copenhagen University Hospital, Herlev, Denmark
| | - Liselotte Skov
- 1 Department of Paediatrics, Copenhagen University Hospital, Herlev, Denmark
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Darrow SM, Hirschtritt ME, Davis LK, Illmann C, Osiecki L, Grados M, Sandor P, Dion Y, King R, Pauls D, Budman CL, Cath DC, Greenberg E, Lyon GJ, Yu D, McGrath LM, McMahon WM, Lee PC, Delucchi KL, Scharf JM, Mathews CA. Identification of Two Heritable Cross-Disorder Endophenotypes for Tourette Syndrome. Am J Psychiatry 2017; 174:387-396. [PMID: 27809572 PMCID: PMC5378637 DOI: 10.1176/appi.ajp.2016.16020240] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Phenotypic heterogeneity in Tourette syndrome is partly due to complex genetic relationships among Tourette syndrome, obsessive-compulsive disorder (OCD), and attention deficit hyperactivity disorder (ADHD). Identifying symptom-based endophenotypes across diagnoses may aid gene-finding efforts. METHOD Assessments for Tourette syndrome, OCD, and ADHD symptoms were conducted in a discovery sample of 3,494 individuals recruited for genetic studies. Symptom-level factor and latent class analyses were conducted in Tourette syndrome families and replicated in an independent sample of 882 individuals. Classes were characterized by comorbidity rates and proportion of parents included. Heritability and polygenic load associated with Tourette syndrome, OCD, and ADHD were estimated. RESULTS The authors identified two cross-disorder symptom-based phenotypes across analyses: symmetry (symmetry, evening up, checking obsessions; ordering, arranging, counting, writing-rewriting compulsions, repetitive writing tics) and disinhibition (uttering syllables/words, echolalia/palilalia, coprolalia/copropraxia, and obsessive urges to offend/mutilate/be destructive). Heritability estimates for both endophenotypes were high and statistically significant (disinhibition factor=0.35, SE=0.03; symmetry factor=0.39, SE=0.03; symmetry class=0.38, SE=0.10). Mothers of Tourette syndrome probands had high rates of symmetry (49%) but not disinhibition (5%). Polygenic risk scores derived from a Tourette syndrome genome-wide association study (GWAS) were significantly associated with symmetry, while risk scores derived from an OCD GWAS were not. OCD polygenic risk scores were significantly associated with disinhibition, while Tourette syndrome and ADHD risk scores were not. CONCLUSIONS The analyses identified two heritable endophenotypes related to Tourette syndrome that cross traditional diagnostic boundaries. The symmetry phenotype correlated with Tourette syndrome polygenic load and was present in otherwise Tourette-unaffected mothers, suggesting that this phenotype may reflect additional Tourette syndrome (rather than OCD) genetic liability that is not captured by traditional DSM-based diagnoses.
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Affiliation(s)
| | | | - Lea K. Davis
- Vanderbilt University Department of Medicine, Nashville
| | - Cornelia Illmann
- Psychiatric and Neurodevelopmental Genetics Unit, Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Lisa Osiecki
- Psychiatric and Neurodevelopmental Genetics Unit, Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Marco Grados
- Johns Hopkins University School of Medicine Department of Psychiatry and Behavioral Sciences, Baltimore
| | - Paul Sandor
- University of Toronto Department of Psychiatry and University Health Network, and Youthdale Treatment Centers, Ontario, Canada
| | - Yves Dion
- University of Montreal Department of Psychiatry, Quebec, Canada
| | - Robert King
- Yale Child Study Center, Yale University School of Medicine Department of Genetics, New Haven
| | - David Pauls
- Psychiatric and Neurodevelopmental Genetics Unit, Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Cathy L. Budman
- North Shore/Long Island Jewish Health System, Feinstein Institute for Medical Research, Manhasset
| | - Danielle C. Cath
- Utrecht University Faculty of Social and Behavioural Sciences, Utrecht, The Netherlands
| | - Erica Greenberg
- Psychiatric and Neurodevelopmental Genetics Unit, Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Gholson J. Lyon
- Stanley Institute for Cognitive Genomics, Cold Spring Harbor Laboratory, Cold Spring Harbor
| | - Dongmei Yu
- Psychiatric and Neurodevelopmental Genetics Unit, Department of Psychiatry, Massachusetts General Hospital, Boston
| | | | | | - Paul C. Lee
- Tripler Army Medical Center Department of Behavioral Health, Honolulu
| | | | - Jeremiah M. Scharf
- Psychiatric and Neurodevelopmental Genetics Unit, Department of Psychiatry, Massachusetts General Hospital, Boston,Departments of Neurology, Brigham and Women’s and Massachusetts General Hospitals, Boston
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Abstract
Tourette syndrome is a neuropsychiatric condition characterized by both motor and phonic tics over a period of at least 1 year with the onset in childhood or adolescence. Apart from the tics, most of the patients with Tourette syndrome have associated neuropsychiatric comorbidities consisting of attention deficit hyperactivity disorder, obsessive compulsive disorder, rage attacks, sleep issues, depression, and migraine. Patients may also have physical complications directly from violent motor tics which can rarely include cervical myelopathy, arterial dissection, and stroke. The purpose of this article is to review the associated neuropsychiatric comorbidities of Tourette syndrome with emphasis on recent research.
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Hirschtritt ME, Darrow SM, Illmann C, Osiecki L, Grados M, Sandor P, Dion Y, King RA, Pauls DL, Budman CL, Cath DC, Greenberg E, Lyon GJ, Yu D, McGrath LM, McMahon WM, Lee PC, Delucchi KL, Scharf JM, Mathews CA. Social disinhibition is a heritable subphenotype of tics in Tourette syndrome. Neurology 2016; 87:497-504. [PMID: 27371487 PMCID: PMC4970665 DOI: 10.1212/wnl.0000000000002910] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 03/28/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To identify heritable symptom-based subtypes of Tourette syndrome (TS). METHODS Forty-nine motor and phonic tics were examined in 3,494 individuals (1,191 TS probands and 2,303 first-degree relatives). Item-level exploratory factor and latent class analyses (LCA) were used to identify tic-based subtypes. Heritabilities of the subtypes were estimated, and associations with clinical characteristics were examined. RESULTS A 6-factor exploratory factor analysis model provided the best fit, which paralleled the somatotopic representation of the basal ganglia, distinguished simple from complex tics, and separated out socially disinhibited and compulsive tics. The 5-class LCA model best distinguished among the following groups: unaffected, simple tics, intermediate tics without social disinhibition, intermediate with social disinhibition, and high rates of all tic types. Across models, a phenotype characterized by high rates of social disinhibition emerged. This phenotype was associated with increased odds of comorbid psychiatric disorders, in particular, obsessive-compulsive disorder and attention-deficit/hyperactivity disorder, earlier age at TS onset, and increased tic severity. The heritability estimate for this phenotype based on the LCA was 0.53 (SE 0.08, p 1.7 × 10(-18)). CONCLUSIONS Expanding on previous modeling approaches, a series of TS-related phenotypes, including one characterized by high rates of social disinhibition, were identified. These phenotypes were highly heritable and may reflect underlying biological networks more accurately than traditional diagnoses, thus potentially aiding future genetic, imaging, and treatment studies.
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Affiliation(s)
- Matthew E Hirschtritt
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Sabrina M Darrow
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Cornelia Illmann
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Lisa Osiecki
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Marco Grados
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Paul Sandor
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Yves Dion
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Robert A King
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - David L Pauls
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Cathy L Budman
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Danielle C Cath
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Erica Greenberg
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Gholson J Lyon
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Dongmei Yu
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Lauren M McGrath
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - William M McMahon
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Paul C Lee
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Kevin L Delucchi
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
| | - Jeremiah M Scharf
- From the Department of Psychiatry (M.E.H., S.M.D., K.L.D.), University of California, San Francisco; Psychiatric and Neurodevelopmental Genetics Unit (C.I., L.O., D.L.P., E.G., D.Y., J.M.S.), Center for Human Genetics Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry and Behavioral Sciences (M.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry (P.S.), University of Toronto and University Health Network, Youthdale Treatment Centers; Department of Psychiatry (Y.D.), University of Montreal, Canada; Yale Child Study Center (R.A.K.), Yale University School of Medicine, New Haven, CT; The Feinstein Institute for Medical Research (C.L.B.), North Shore Long Island Jewish Health System, Manhasset, NY; Faculty of Social and Behavioural Sciences (D.C.C.), Utrecht University and Altrecht Academic Anxiety Center, Utrecht, the Netherlands; Stanley Institute for Cognitive Genomics (G.J.L.), Cold Spring Harbor Laboratory, NY; School of Education (L.M.M.), American University, Washington, DC; Department of Psychiatry (W.M.M.), University of Utah, Salt Lake City; Department of Behavioral Health (P.C.L.), Tripler Army Medical Center, Honolulu, HI; Division of Cognitive and Behavioral Neurology (J.M.S.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (J.M.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; and Department of Psychiatry (C.A.M.), University of Florida, Gainesville
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Huisman-van Dijk HM, van de Schoot R, Rijkeboer MM, Mathews CA, Cath DC. The relationship between tics, OC, ADHD and autism symptoms: A cross- disorder symptom analysis in Gilles de la Tourette syndrome patients and family-members. Psychiatry Res 2016; 237:138-46. [PMID: 26826899 PMCID: PMC5137472 DOI: 10.1016/j.psychres.2016.01.051] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 11/21/2015] [Accepted: 01/21/2016] [Indexed: 01/22/2023]
Abstract
Gilles de la Tourette's syndrome (GTS) is a disorder in which obsessive-compulsive (OC), Attention Deficit Hyperactivity Disorder (ADHD) and autism symptoms occur in up to 60% of patients, suggesting shared etiology. We explored the phenotypic structure of tic, OC, ADHD, and autism symptoms as measured by the YGTSS,Y-BOCS,CAARS and AQ, in 225 GTS patients and 371 family members. First, Confirmatory Factor Analyses (CFA) were performed on the symptom structure of each separate symptom scale. Second, the symptom dimensions derived from each scale were combined in one model, and correlations between them were calculated. Using the correlation matrix, Exploratory Factor Analyses (EFA) were performed on the symptom dimensions across the scales. EFA revealed a five factor structure: tic/aggression/symmetry; OC symptoms/compulsive tics/ numbers and patterns; ADHD symptoms; autism symptoms; and hoarding/inattention symptoms. The results are partly in line with the traditional categorical boundaries of the symptom scales used, and partly reveal a symptom structure that cuts through the diagnostic categories. This phenotypic structure might more closely reflect underlying etiologies than a structure that classically describes GTS patients according to absence or presence of comorbid OCD, ADHD and autism, and might inform both future genetic and treatment studies.
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Affiliation(s)
- Hilde M. Huisman-van Dijk
- Department of Clinical and Health Psychology, Faculty of Social
Sciences, Utrecht University, Netherlands,Altrecht Academic Anxiety Center, Utrecht, Netherlands
| | - Rens van de Schoot
- Department of Methods & Statistics, Faculty of Social
Sciences, Utrecht University, Netherlands,Optentia Research Program, Faculty of Humanities, North-West
University, South Africa
| | - Marleen M. Rijkeboer
- Department of Clinical and Health Psychology, Faculty of Social
Sciences, Utrecht University, Netherlands
| | - Carol A Mathews
- Department of Psychiatry, School of Medicine, University of
California, San Francisco, United States of America
| | - Dainelle C Cath
- Department of Clinical and Health Psychology, Faculty of Social
Sciences, Utrecht University, Netherlands,Altrecht Academic Anxiety Center, Utrecht, Netherlands
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Abstract
INTRODUCTION Gilles de la Tourette's syndrome (TS) is both genotypically and phenotypically heterogeneous. Gene-finding strategies have had limited success, possibly because of symptom heterogeneity. OBJECTIVE This study aimed at specifically investigating heritabilities of tic symptom factors in a relatively large sample of TS patients and family members. PARTICIPANTS AND METHODS Lifetime tic symptom data were collected in 494 diagnosed individuals in two cohorts of TS patients from the USA (n=273) and the Netherlands (n=221), and in 351 Dutch family members. Item-level factor analysis, using a tetrachoric correlation matrix in SAS (v9.2), was carried out on 23 tic symptoms from the Yale Global Tic Severity Scale. RESULTS Three factors were identified explaining 49% of the total variance: factor 1, complex vocal tics and obscene behaviour; factor 2, body tics; and factor 3, head/neck tics. Using Sequential Oligogenic Linkage Analysis Routine, moderate heritabilities were found for factor 1 (h2r=0.21) and factor 3 (h2r=0.25). Lower heritability was found for overall tic severity (h2r=0.19). Bivariate analyses indicated no genetic associations between tic factors. CONCLUSION These findings suggest that (i) three tic factors can be discerned with a distinct underlying genetic architecture and that (ii) considering the low tic heritabilities found, only focusing on the narrow-sense TS phenotype and leaving out comorbidities that are part of the broader sense tic phenotype may lead to missing heritability. Although these findings need replication in larger independent samples, they might have consequences for future genetic studies in TS.
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Hawksley J, Cavanna AE, Nagai Y. The role of the autonomic nervous system in Tourette Syndrome. Front Neurosci 2015; 9:117. [PMID: 26074752 PMCID: PMC4444819 DOI: 10.3389/fnins.2015.00117] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/23/2015] [Indexed: 11/13/2022] Open
Abstract
Tourette Syndrome (TS) is a neurodevelopmental disorder, consisting of multiple involuntary movements (motor tics) and one or more vocal (phonic) tics. It affects up to one percent of children worldwide, of whom about one third continue to experience symptoms into adulthood. The central neural mechanisms of tic generation are not clearly understood, however recent neuroimaging investigations suggest impaired cortico-striato-thalamo-cortical activity during motor control. In the current manuscript, we will tackle the relatively under-investigated role of the peripheral autonomic nervous system, and its central influences, on tic activity. There is emerging evidence that both sympathetic and parasympathetic nervous activity influences tic expression. Pharmacological treatments which act on sympathetic tone are often helpful: for example, Clonidine (an alpha-2 adrenoreceptor agonist) is often used as first choice medication for treating TS in children due to its good tolerability profile and potential usefulness for co-morbid attention-deficit and hyperactivity disorder. Clonidine suppresses sympathetic activity, reducing the triggering of motor tics. A general elevation of sympathetic tone is reported in patients with TS compared to healthy people, however this observation may reflect transient responses coupled to tic activity. Thus, the presence of autonomic impairments in patients with TS remains unclear. Effect of autonomic afferent input to cortico-striato-thalamo-cortical circuit will be discussed schematically. We additionally review how TS is affected by modulation of central autonomic control through biofeedback and Vagus Nerve Stimulation (VNS). Biofeedback training can enable a patient to gain voluntary control over covert physiological responses by making these responses explicit. Electrodermal biofeedback training to elicit a reduction in sympathetic tone has a demonstrated association with reduced tic frequency. VNS, achieved through an implanted device that gives pulsatile electrical stimulation to the vagus nerve, directly modulates afferent interoceptive signals. The potential efficacy of biofeedback/VNS in TS and the implications for understanding the underlying neural mechanisms of tics will be discussed.
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Affiliation(s)
- Jack Hawksley
- North Essex Partnership University NHS Foundation Trust Colchester, UK
| | - Andrea E Cavanna
- Department of Neuropsychiatry, Birmingham and Solihull Mental Health NHS Trust and School of Clinical and Experimental Medicine, University of Birmingham Birmingham, UK
| | - Yoko Nagai
- Department of Clinical Medicine, Clinical Imaging Sciences Center, Brighton and Sussex Medical School, University of Sussex Brighton, UK ; Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London London, UK
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El Malhany N, Gulisano M, Rizzo R, Curatolo P. Tourette syndrome and comorbid ADHD: causes and consequences. Eur J Pediatr 2015; 174:279-88. [PMID: 25224657 DOI: 10.1007/s00431-014-2417-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/27/2014] [Accepted: 09/01/2014] [Indexed: 12/17/2022]
Abstract
UNLABELLED Attention deficit hyperactivity disorder (ADHD) is the most common comorbid condition in patients with Tourette syndrome (TS). The co-occurrence of ADHD and TS is in most cases associated with a higher social and psychopathological impairment. Comorbidity between Tourette and ADHD appears to have a complex and partially known pathogenesis in which genetic, environmental, and neurobiological factors can be implicated. Genetic studies have revealed an involvement of dopaminergic, catecholaminergic, and GABAergic genes that modulated the activity of neurotransmitters. Furthermore, there are a lot of networks implicated in the development of ADHD and TS, involving cortical and striatal areas and basal ganglia. Although a large number of studies tried to find a common pathogenesis, the complex pathways responsible are not clear. The genes implicated in both disorders are currently unidentified, but it is probable that epigenetic factors associated with neural modifications can represent a substrate for the development of the diseases. CONCLUSION In this paper, recent advances in neurobiology of ADHD and TS are reviewed, providing a basis for understanding the complex common pathogenesis underlying the frequent co-occurrence of the two conditions and the therapeutic choices.
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Affiliation(s)
- N El Malhany
- Section of Child Neuropsychiatry, Department of Neurosciences, Tor Vergata University, Viale Oxford 81, 00133, Rome, Italy,
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A personal 35 year perspective on Gilles de la Tourette syndrome: prevalence, phenomenology, comorbidities, and coexistent psychopathologies. Lancet Psychiatry 2015; 2:68-87. [PMID: 26359614 DOI: 10.1016/s2215-0366(14)00132-1] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 09/15/2014] [Indexed: 02/07/2023]
Abstract
This Series is a personal narrative of my experience with patients with Gilles de la Tourette syndrome and covers its definition and history since the first description in 1825. Controversy entered the prevalence debate early. Although originally considered very rare, in the 1980s, Tourette's syndrome was reported to be common. However, Tourette's syndrome has been shown to occur at a prevalence of about 0·85% to 1%. Tourette's syndrome is more common in the male population, more prominent during childhood, and usually improves, but does not disappear with age. Tourette's syndrome is considered less common in people of sub-Saharan black African, African-American, and American Hispanic ethnic origin. The phenomenology is similar worldwide, indicating a biological basis. The hallmark characteristics are multiple motor and one or more vocal/phonic tics. Other associated features include premonitory urges, a waxing and waning course, and to a much lesser degree, coprolalia. Comorbid disorders are common and are suggested to include obsessive-compulsive disorder and behaviours, attention deficit hyperactivity disorder, and autistic spectrum disorder. Coexistent psychopathologies are suggested to include depression and conduct and personality disorders. Importantly, I argue that Tourette's syndrome is not a unitary condition. Finally, I offer suggestions for future research.
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Heym N, Kantini E, Checkley HLR, Cassaday HJ. Tourette-like behaviors in the normal population are associated with hyperactive/impulsive ADHD-like behaviors but do not relate to deficits in conditioned inhibition or response inhibition. Front Psychol 2014; 5:946. [PMID: 25228890 PMCID: PMC4151087 DOI: 10.3389/fpsyg.2014.00946] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 08/07/2014] [Indexed: 11/21/2022] Open
Abstract
Attention-Deficit Hyperactivity Disorder (ADHD) and Tourette Syndrome (TS) present as distinct conditions clinically; however, comorbidity and inhibitory control deficits have been proposed for both. Whilst such deficits have been studied widely within clinical populations, findings are mixed—partly due to comorbidity and/or medication effects—and studies have rarely distinguished between subtypes of the disorders. Studies in the general population are sparse. Using a continuity approach, the present study examined (i) the relationships between inattentive and hyperactive/impulsive aspects of ADHD and TS-like behaviors in the general population, and (ii) their unique associations with automatic and executive inhibitory control, as well as (iii) yawning (a proposed behavioral model of TS). One hundred and thirty-eight participants completed self-report measures for ADHD and TS-like behaviors as well as yawning, and a conditioned inhibition task to assess automatic inhibition. A sub-sample of fifty-four participants completed three executive inhibition tasks. An exploratory factor analysis of the TS behavior checklist supported a distinction between phonic and motor like pure TS behaviors. Whilst hyperactive/impulsive aspects of ADHD were associated with increased pure and compulsive TS-like behaviors, inattention in isolation was related to reduced obsessive-compulsive TS-like behaviors. TS-like behaviors were associated with yawning during situations of inactivity, and specifically motor TS was related to yawning during stress. Phonic TS and inattention aspects of ADHD were associated with yawning during concentration/activity. Whilst executive interference control deficits were linked to hyperactive/impulsive ADHD-like behaviors, this was not the case for inattentive ADHD or TS-like behaviors, which instead related to increased performance on some measures. No associations were observed for automatic conditioned inhibition.
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Affiliation(s)
- Nadja Heym
- School of Psychology, University of Nottingham Nottingham, UK ; Division of Psychology, School of Social Science, Nottingham Trent University Nottingham, UK
| | - Ebrahim Kantini
- School of Psychology, University of Nottingham Nottingham, UK
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Ganos C, Münchau A, Bhatia KP. The Semiology of Tics, Tourette's, and Their Associations. Mov Disord Clin Pract 2014; 1:145-153. [PMID: 30363870 PMCID: PMC6183022 DOI: 10.1002/mdc3.12043] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/24/2014] [Accepted: 04/24/2014] [Indexed: 01/01/2023] Open
Abstract
Gilles de la Tourette syndrome (GTS) is a prototypical neuropsychiatric disorder breaking the boundary of disciplinary dualism between neurology and psychiatry. The diagnosis of GTS is clinical and, in most cases, straightforward. Tics as a hallmark of GTS are usually easy to recognize and distinguish from other movement disorders as fragmented, repetitive, exaggerated movements resembling normal motor behavior, but appearing out of context. In complex cases, knowledge on additional characteristics and signs as, for example, tic distribution, suggestibility, voluntary tic inhibition, and presence of echo- or paliphenomena might further aid clinical diagnosis. However, although defining GTS, tics are rarely the main issue. The presence of comorbidities and coexisting psychopathologies often hampers normal development and negatively affects quality of life. Their recognition and treatment is paramount. Here, we review existing literature and provide a comprehensive update on the multifarious aspects of the movement disorder and neuropsychiatry of GTS. We also provide a list of associated movement disorders known to occur in GTS patients and discuss differential diagnoses to be considered in atypical cases. We finally comment on available treatment options.
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Affiliation(s)
- Christos Ganos
- Sobell Department of Motor Neuroscience and Movement DisordersUCL Institute of NeurologyLondonUnited Kingdom
- Department of NeurologyUniversity Medical Center Hamburg‐Eppendorf (UKE)HamburgGermany
- Department of Pediatric and Adult Movement Disorders and NeuropsychiatryInstitute of NeurogeneticsUniversity of LübeckLübeckGermany
| | - Alexander Münchau
- Department of Pediatric and Adult Movement Disorders and NeuropsychiatryInstitute of NeurogeneticsUniversity of LübeckLübeckGermany
| | - Kailash P. Bhatia
- Sobell Department of Motor Neuroscience and Movement DisordersUCL Institute of NeurologyLondonUnited Kingdom
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Biomedical Text Mining: State-of-the-Art, Open Problems and Future Challenges. INTERACTIVE KNOWLEDGE DISCOVERY AND DATA MINING IN BIOMEDICAL INFORMATICS 2014. [DOI: 10.1007/978-3-662-43968-5_16] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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A cluster analysis of tic symptoms in children and adults with Tourette syndrome: clinical correlates and treatment outcome. Psychiatry Res 2013; 210:1198-204. [PMID: 24144615 PMCID: PMC3941714 DOI: 10.1016/j.psychres.2013.09.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 09/11/2013] [Accepted: 09/20/2013] [Indexed: 12/13/2022]
Abstract
Cluster analytic methods have examined the symptom presentation of chronic tic disorders (CTDs), with limited agreement across studies. The present study investigated patterns, clinical correlates, and treatment outcome of tic symptoms. 239 youth and adults with CTDs completed a battery of assessments at baseline to determine diagnoses, tic severity, and clinical characteristics. Participants were randomly assigned to receive either a comprehensive behavioral intervention for tics (CBIT) or psychoeducation and supportive therapy (PST). A cluster analysis was conducted on the baseline Yale Global Tic Severity Scale (YGTSS) symptom checklist to identify the constellations of tic symptoms. Four tic clusters were identified: Impulse Control and Complex Phonic Tics; Complex Motor Tics; Simple Head Motor/Vocal Tics; and Primarily Simple Motor Tics. Frequencies of tic symptoms showed few differences across youth and adults. Tic clusters had small associations with clinical characteristics and showed no associations to the presence of coexisting psychiatric conditions. Cluster membership scores did not predict treatment response to CBIT or tic severity reductions. Tic symptoms distinctly cluster with little difference across youth and adults, or coexisting conditions. This study, which is the first to examine tic clusters and response to treatment, suggested that tic symptom profiles respond equally well to CBIT. Clinical trials.gov. identifiers: NCT00218777; NCT00231985.
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Neal M, Cavanna AE. "Not just right experiences" in patients with Tourette syndrome: complex motor tics or compulsions? Psychiatry Res 2013; 210:559-63. [PMID: 23850205 DOI: 10.1016/j.psychres.2013.06.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 03/11/2013] [Accepted: 06/22/2013] [Indexed: 10/26/2022]
Abstract
Tourette syndrome (TS) is a chronic tic disorder often accompanied by specific obsessive-compulsive symptoms (OCS) or full-blown obsessive-compulsive disorder (OCD). Repetitive behaviours are commonly reported by patients with TS, who experience the urge to perform an action until it has been done "just right". This study investigated the clinical correlates of "not just right experiences" (NJREs) in this clinical population. A standardised battery of self-report psychometric measures was administered to 71 adult patients with TS recruited from a specialist TS clinic. NJREs were systematically screened for using the Not Just Right Experiences-Questionnaire Revised (NJRE-QR). The vast majority of patients in our clinical sample (n=57, 80%) reported at least one NJRE. Patients diagnosed with TS and co-morbid OCD/OCS (n=42, 59%) reported a significantly higher number of NJREs compared to TS patients without OCD/OCS. The strongest correlation was found between NJRE-QR scores and self-report measures of compulsivity. NJREs appear to be intrinsic to the clinical phenomenology of patients with TS and can present with higher frequency in the context of co-morbid OCD/OCS, suggesting they are more related to compulsions than tics.
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Affiliation(s)
- Matthew Neal
- The Michael Trimble Neuropsychiatry Research Group, Department of Neuropsychiatry, BSMHFT and University of Birmingham, United Kingdom
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Rodgers S, Müller M, Kawohl W, Knöpfli D, Rössler W, Castelao E, Preisig M, Ajdacic-Gross V. Sex-related and non-sex-related comorbidity subtypes of tic disorders: a latent class approach. Eur J Neurol 2013; 21:700-7, e44-5. [PMID: 24118249 DOI: 10.1111/ene.12274] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 08/23/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Recent evidence suggests that there may be more than one Gilles de la Tourette syndrome (GTS)/tic disorder phenotype. However, little is known about the common patterns of these GTS/tic disorder-related comorbidities. In addition, sex-specific phenomenological data of GTS/tic disorder-affected adults are rare. Therefore, this community-based study used latent class analyses (LCA) to investigate sex-related and non-sex-related subtypes of GTS/tic disorders and their most common comorbidities. METHODS The data were drawn from the PsyCoLaus study (n = 3691), a population-based survey conducted in Lausanne, Switzerland. LCA were performed on the data of 80 subjects manifesting motor/vocal tics during their childhood/adolescence. Comorbid attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, depressive, phobia and panic symptoms/syndromes comprised the selected indicators. The resultant classes were characterized by psychosocial correlates. RESULTS In LCA, four latent classes provided the best fit to the data. We identified two male-related classes. The first class exhibited both ADHD and depression. The second class comprised males with only depression. Class three was a female-related class depicting obsessive thoughts/compulsive acts, phobias and panic attacks. This class manifested high psychosocial impairment. Class four had a balanced sex proportion and comorbid symptoms/syndromes such as phobias and panic attacks. The complementary occurrence of comorbid obsessive thoughts/compulsive acts and ADHD impulsivity was remarkable. CONCLUSIONS To the best of our knowledge, this is the first study applying LCA to community data of GTS symptoms/tic disorder-affected persons. Our findings support the utility of differentiating GTS/tic disorder subphenotypes on the basis of comorbid syndromes.
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Affiliation(s)
- S Rodgers
- Department of Psychiatry, Psychotherapy and Psychosomatics, Zurich University Hospital of Psychiatry, Zurich, Switzerland
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Chovaz CJ. Report of a deaf child with Tourette's disorder. JOURNAL OF DEAF STUDIES AND DEAF EDUCATION 2013; 18:360-369. [PMID: 23532912 DOI: 10.1093/deafed/ent014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This is a case study of a deaf child with Tourette's Disorder (TD). Hearing parents and mental health clinicians unfamiliar with typical behaviors of deaf children may have difficulties differentiating the clinical presentation of symptoms of TD from the effects of deafness, as well as in implementing appropriate interventions. This case study reports the history, symptoms, diagnostic process, and treatment interventions. This is relevant for furthering the clinical knowledge of mental health professionals working with Deaf, deaf, and hard-of-hearing children and adolescents.
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Affiliation(s)
- Cathy J Chovaz
- Kings University College at Western University, 266 Epworth Avenue, London, ON, Canada.
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The psychopathological spectrum of Gilles de la Tourette syndrome. Neurosci Biobehav Rev 2012; 37:1008-15. [PMID: 23131314 DOI: 10.1016/j.neubiorev.2012.10.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 10/16/2012] [Accepted: 10/28/2012] [Indexed: 02/06/2023]
Abstract
Gilles de la Tourette syndrome (GTS) holds a unique status as quintessentially neuropsychiatric condition at the interface between neurology (movement disorder) and psychiatry (behavioural condition). This is a reflection of the common observation that the vast majority of patients present with behavioural problems in association with the motor and vocal tics which define GTS. The present article focuses on the relationship between GTS and obsessive-compulsive disorder (OCD), attention-deficit and hyperactivity disorder (ADHD), affective disorders (both major depression and bipolar affective disorder), and personality disorders. Over the last decade, converging lines of research have pointed towards the concept of a 'GTS spectrum', encompassing motor phenomena and behavioural symptoms, with important implications for the clinical management of patients.
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Porta M, Servello D, Zanaboni C, Anasetti F, Menghetti C, Sassi M, Robertson MM. Deep brain stimulation for treatment of refractory Tourette syndrome: long-term follow-up. Acta Neurochir (Wien) 2012; 154:2029-41. [PMID: 22961243 DOI: 10.1007/s00701-012-1497-8] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 08/23/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND Eighteen patients with severe and refractory Tourette Syndrome underwent bilateral thalamic deep brain stimulation. The surgical procedures and stimulation processes of the cohort were reported in 2008; the 2 year follow-up was reported in 2009. The aim of the research is the assessment of long-term outcome (5-6 years) on tics, obsessional behaviours, anxiety, mood, and on the overall general health of the patients and their general satisfaction. METHOD In this study, all 18 of the original patients will be discussed, pre- and post-DBS, according to our protocol using standardized objective schedules, as well as the clinical impressions of both clinicians and patients. As there were no substantial nor statistical differences on measures of cognitive functioning between pre-DBS and 2 year follow-up, we decided not to continue this aspect of the formal assessment, particularly as there were also no clinical indications. RESULTS At 5-6 year follow-up, there was a significant reduction in tic severity (p < 0.001), and significant improvements in obsessive compulsive behaviours (p = 0.003), anxiety (p < 0.001) and depressive (p < 0.001) symptoms. Patients, in general, required less medication for tics, co-morbid conditions and/or co-existent psychopathologies. The long-term outcome/satisfaction were not unanimous between patients and the medical team. CONCLUSIONS At long-term follow-up, DBS was very successful in terms of a significant improvement in tics and also a significant reduction in the potentially disabling symptoms of obsessionality, anxiety and depression. However, compared with our more positive overall results at 2 years, these later results demonstrate long-term difficulties as follows: non-compliance, long-term complications , and the differences in the opinions between the (a) medical, (b) the surgical teams and (c) the post-DBS patients as to their outcome/satisfaction with the procedures. Our experience highlights the need for controlled studies, for long-term follow up, and the need to improve the selection of patients for DBS.
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Affiliation(s)
- M Porta
- Tourette Center- IRCCS Galeazzi Hospital, via R. Galeazzi 4, 20161, Milano, Italy.
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Rizzo R, Gulisano M, Calì PV, Curatolo P. Long term clinical course of Tourette syndrome. Brain Dev 2012; 34:667-73. [PMID: 22178151 DOI: 10.1016/j.braindev.2011.11.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 11/17/2011] [Accepted: 11/19/2011] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recent studies using cluster analysis and factor analysis have suggested that Tourette Syndrome (TS) should no longer be considered a unitary condition. MATERIAL AND METHODS We retrospectively studied the long term clinical course of 100 TS patients. The patients were assessed at the onset and after 10 years follow-up to evaluate the severity of tic, the Obsessive Compulsive Disorder (OCD), the Attention Deficit Hyperactivity Disorder (ADHD) and the presence of anxiety and depression, rage attacks, self injuries behavior. Moreover at the follow-up they completed an evaluation scale on quality of life to assess the impairment in everyday life after 10 years of illness. RESULTS The "pure TS" clinical group (38 subjects) showed after 10 years follow-up that 58% carried on with the same clinical phenotype, whereas 42% changed in "TS+OCD" phenotype. Fifty-five percentage required pharmacological treatment. All the "TS+ADHD" clinical group (48 subjects) showed after 10 years follow-up a different clinical phenotype: 62% "TS pure" phenotype, 35% "TS+OCD" phenotype, 2% "TS+ADHD+OCD" phenotype. Sixty-five percentage of the subject required pharmacological treatment. The "TS+ADHD+OCD" clinical group (14 subjects) after 10 years follow-up showed that 14% carried on with the same clinical phenotype, whereas 8.3% presented "TS pure" phenotype and 92% presented "TS+OCD" phenotype. Seventy-one percentage were in need of therapy. With regards to quality of life, patients presented widespread impairment correlated to the presence of comorbid conditions. CONCLUSION Our findings suggest that pure TS has quite a good long-term clinical course. By contrast, those who presented comorbid condition at the onset showed a more severe prognosis.
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Affiliation(s)
- Renata Rizzo
- Section of Child Neuropsychiatry, Maternal-Infantile and Radiological Sciences Department, Catania University, Via Santa Sofia 78, 95123 Catania, Italy.
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Robertson MM. Gilles de la Tourette syndrome: the complexities of phenotype and treatment. Br J Hosp Med (Lond) 2011; 72:100-7. [DOI: 10.12968/hmed.2011.72.2.100] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Mary M Robertson
- Professor Mary M Robertson is Emeritus Professor of Neuropsychiatry, University College London and Visiting Professor and Honorary Consultant, Department of Neurology, St Georges Hospital and Medical School, London SW17 0QT
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Hartmann A, van Meerbeeck P, Deniau E, Béhar C, Czernecki V, Depienne C, Worbe Y. Tic e sindrome di Gilles de la Tourette. Neurologia 2011. [DOI: 10.1016/s1634-7072(11)70624-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Familiality of Tourette syndrome, obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder: heritability analysis in a large sib-pair sample. J Am Acad Child Adolesc Psychiatry 2011; 50:46-54. [PMID: 21156269 PMCID: PMC3035426 DOI: 10.1016/j.jaac.2010.10.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 10/12/2010] [Accepted: 10/18/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Tourette syndrome (TS) is a neuropsychiatric disorder with a genetic component that is highly comorbid with obsessive-compulsive disorder (OCD) and attention deficit/hyperactivity disorder (ADHD). However, the genetic relations between these disorders have not been clearly elucidated. This study examined the familial relations among TS, OCD, and ADHD in a large sample of TS families. METHOD Parent-offspring concordance of TS, OCD, and ADHD was examined in 952 individuals from 222 TS-affected sib-pair families originally collected for genetic studies using logistic regression with generalized estimating equations to control for correlated data. Variance components methods were used to estimate the heritability and genetic and environmental correlations among TS, OCD, and ADHD. Bilineal families where both parents had TS or OCD were excluded. RESULTS OCD and ADHD were highly heritable in these TS families. There were significant genetic correlations between TS and OCD and between OCD and ADHD, but not between TS and ADHD. In addition, significant environmental correlations were found between TS and ADHD and between OCD and ADHD. Parental OCD + ADHD was associated with offspring OCD + ADHD. CONCLUSIONS This study provides further evidence for a genetic relation between TS and OCD and suggests that the observed relation between TS and ADHD may due in part be to a genetic association between OCD and ADHD and in part due to shared environmental factors.
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Cluster analysis of the Yale Global Tic Severity Scale (YGTSS): symptom dimensions and clinical correlates in an outpatient youth sample. JOURNAL OF ABNORMAL CHILD PSYCHOLOGY 2010; 38:777-88. [PMID: 20386987 PMCID: PMC2902733 DOI: 10.1007/s10802-010-9410-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Tic disorders are heterogeneous, with symptoms varying widely both within and across patients. Exploration of symptom clusters may aid in the identification of symptom dimensions of empirical and treatment import. This article presents the results of two studies investigating tic symptom clusters using a sample of 99 youth (M age = 10.7, 81% male, 77% Caucasian) diagnosed with a primary tic disorder (Tourette’s disorder or chronic tic disorder), across two university-based outpatient clinics specializing in tic and related disorders. In Study 1, a cluster analysis of the Yale Global Tic Severity Scale (YGTSS) identified four symptom dimensions: predominantly complex tics; simple head/face tics; simple body tics; and simple vocal/facial tics. In Study 2, these clusters were shown to be differentially associated with demographic and clinical characteristics. Findings lend support to prior research on tic phenomenology, help to organize treatment goals, and suggest symptom dimensions of tic disorders for further evaluation.
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Worbe Y, Gerardin E, Hartmann A, Valabrégue R, Chupin M, Tremblay L, Vidailhet M, Colliot O, Lehéricy S. Distinct structural changes underpin clinical phenotypes in patients with Gilles de la Tourette syndrome. ACTA ACUST UNITED AC 2010; 133:3649-60. [PMID: 20959309 DOI: 10.1093/brain/awq293] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Gilles de la Tourette syndrome is a childhood-onset neurodevelopmental disorder characterized by tics that are often associated with psychiatric co-morbidities. The clinical heterogeneity of Gilles de la Tourette syndrome has been attributed to the disturbance of functionally distinct cortico-striato-thalamo-cortical circuits, but this remains to be demonstrated. The aim of this study was to determine the structural correlates of the diversity of symptoms observed in Gilles de la Tourette syndrome. We examined 60 adult patients and 30 age- and gender-matched control subjects using cortical thickness measurement and 3 T high-resolution T(1)-weighted images. Patients were divided into three clinical subgroups: (i) simple tics; (ii) simple and complex tics and (iii) tics with associated obsessive-compulsive disorders. Patients with Gilles de la Tourette syndrome had reduced cortical thickness in motor, premotor, prefrontal and lateral orbito-frontal cortical areas. The severity of tics was assessed using the Yale Global Tic Severity Scale and correlated negatively with cortical thinning in these regions, as well as in parietal and temporal cortices. The pattern of cortical thinning differed among the clinical subgroups of patients. In patients with simple tics, cortical thinning was mostly found in primary motor regions. In patients with simple and complex tics, thinning extended into larger premotor, prefrontal and parietal regions. In patients with associated obsessive-compulsive disorders, there was a trend for reduced cortical thickness in the anterior cingulate cortex and hippocampal morphology was altered. In this clinical subgroup, scores on the Yale-Brown Obsessive-Compulsive Scale correlated negatively with cortical thickness in the anterior cingulate cortex and positively in medial premotor regions. These data support the hypothesis that different symptom dimensions in Gilles de la Tourette syndrome are associated with dysfunction of distinct cortical areas and have clear implications for the current neuroanatomical model of this syndrome.
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Affiliation(s)
- Yulia Worbe
- Centre d’Investigation Clinique INSERM CIC 9503, Fédération des Maladies du Système Nerveux, Groupe Hospitalier Pitié-Salpêtrière, AssistancePublique-Hôpitaux de Paris, Paris, France.
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Worbe Y, Mallet L, Golmard JL, Béhar C, Durif F, Jalenques I, Damier P, Derkinderen P, Pollak P, Anheim M, Broussolle E, Xie J, Mesnage V, Mondon K, Viallet F, Jedynak P, Djebara MB, Schüpbach M, Pelissolo A, Vidailhet M, Agid Y, Houeto JL, Hartmann A. Repetitive behaviours in patients with Gilles de la Tourette syndrome: tics, compulsions, or both? PLoS One 2010; 5:e12959. [PMID: 20885982 PMCID: PMC2945770 DOI: 10.1371/journal.pone.0012959] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Accepted: 08/29/2010] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Repetitive behaviours (RB) in patients with Gilles de la Tourette syndrome (GTS) are frequent. However, a controversy persists whether they are manifestations of obsessive-compulsive disorder (OCD) or correspond to complex tics. METHODS 166 consecutive patients with GTS aged 15-68 years were recruited and submitted to extensive neurological, psychiatric and psychological evaluations. RB were evaluated by the YBOCS symptom checklist and Mini International Neuropsychiatric Interview (M.I.N.I), and classified on the basis of a semi-directive psychiatric interview as compulsions or tics. RESULTS RB were present in 64.4% of patients with GTS (107/166) and categorised into 3 major groups: a 'tic-like' group (24.3%-40/166) characterised by RB such as touching, counting, 'just right' and symmetry searching; an 'OCD-like' group (20.5%-34/166) with washing and checking rituals; and a 'mixed' group (13.2%-22/166) with both 'tics-like' and 'OCD-like' types of RB present in the same patient. In 6.3% of patients, RB could not be classified into any of these groups and were thus considered 'undetermined'. CONCLUSIONS The results confirm the phenomenological heterogeneity of RB in GTS patients and allows to distinguish two types: tic-like behaviours which are very likely an integral part of GTS; and OCD-like behaviours, which can be considered as a comorbid condition of GTS and were correlated with higher score of complex tics, neuroleptic and SSRIs treatment frequency and less successful socio-professional adaptation. We suggest that a meticulous semiological analysis of RB in GTS patients will help to tailor treatment and allow to better classify patients for future pathophysiologic studies. TRIAL REGISTRATION ClinicalTrials.gov NCT00169351.
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Affiliation(s)
- Yulia Worbe
- Centre d'Investigation Clinique INSERM CIC 9503, Pôle des Maladies du Système Nerveux, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Luc Mallet
- Centre d'Investigation Clinique INSERM CIC 9503, Pôle des Maladies du Système Nerveux, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jean-Louis Golmard
- Département de Biostatistique, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Cécile Béhar
- Centre d'Investigation Clinique INSERM CIC 9503, Pôle des Maladies du Système Nerveux, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Franck Durif
- Département de Neurologie, Centre Hospitalo-Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Isabelle Jalenques
- CHU Clermont-Ferrand, Service de Psychiatrie de l'Adulte A et Psychologie Médicale, Pôle de Psychiatrie, Clermont-Ferrand, France
- Clermont Université, Université d'Auvergne Clermont 1, UFR Médecine, Equipe d'Accueil 3845, Clermont-Ferrand, France
| | - Philippe Damier
- Département de Neurologie, Centre Hospitalo-Universitaire de Nantes, Nantes, France
| | - Pascal Derkinderen
- Département de Neurologie, Centre Hospitalo-Universitaire de Nantes, Nantes, France
| | - Pierre Pollak
- Département de Neurologie, Centre Hospitalo-Universitaire de Grenoble, Grenoble, France
| | - Mathieu Anheim
- Département de Neurologie, Centre Hospitalo-Universitaire de Grenoble, Grenoble, France
| | - Emannuel Broussolle
- Université Claude Bernard Lyon I, Faculté de Médecine Lyon-Sud Charles Mérieux, Hospices Civils de Lyon, Département de Neurologie C, Hôpital Neurologique Pierre Wertheimer, Centre de Neurosciences Cognitives, CNRS UMR 5229, Lyon, France
| | - Jing Xie
- Université Claude Bernard Lyon I, Faculté de Médecine Lyon-Sud Charles Mérieux, Hospices Civils de Lyon, Département de Neurologie C, Hôpital Neurologique Pierre Wertheimer, Centre de Neurosciences Cognitives, CNRS UMR 5229, Lyon, France
| | - Valérie Mesnage
- Département de Neurologie, Centre Hospitalo-Universitaire de Poitiers, Poitiers, France
| | - Karl Mondon
- Département de Neurologie, Centre Hospitalo-Universitaire de Tours, Tours, France
| | - François Viallet
- Département de Neurologie, Centre Hospitalier d'Aix-en-Provence, Aix-en-Provence, France
| | - Pierre Jedynak
- Centre d'Investigation Clinique INSERM CIC 9503, Pôle des Maladies du Système Nerveux, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Mouna Ben Djebara
- Centre d'Investigation Clinique INSERM CIC 9503, Pôle des Maladies du Système Nerveux, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Michael Schüpbach
- Centre d'Investigation Clinique INSERM CIC 9503, Pôle des Maladies du Système Nerveux, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Antoine Pelissolo
- Département de Psychiatrie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Marie Vidailhet
- Centre d'Investigation Clinique INSERM CIC 9503, Pôle des Maladies du Système Nerveux, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Yves Agid
- Centre d'Investigation Clinique INSERM CIC 9503, Pôle des Maladies du Système Nerveux, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jean-Luc Houeto
- Département de Neurologie, Centre Hospitalo-Universitaire de Poitiers, Poitiers, France
| | - Andreas Hartmann
- Centre d'Investigation Clinique INSERM CIC 9503, Pôle des Maladies du Système Nerveux, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie-Paris 6, Paris, France
- * E-mail:
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Selected summaries from the XVII World Congress of Psychiatric Genetics, San Diego, California, USA, 4-8 November 2009. Psychiatr Genet 2010; 20:229-68. [PMID: 20706171 DOI: 10.1097/ypg.0b013e32833d17c3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The XVII World Congress of Psychiatric Genetics, sponsored by The International Society of Psychiatric Genetics (ISPG) took place in San Diego, California from 4 to 8 November 2009. Approximately 550 participants gathered to discuss the latest molecular genetic findings relevant to serious mental illness, including schizophrenia, mood disorders, substance abuse, autism, and attention deficit disorder. Recent advances in the field were discussed, including the genome-wide association studies results, copy number variation (CNV) in the genome, genomic imaging, and large multicenter collaborations. The following report, written by junior travel awardees who were assigned sessions as rapporteurs represents some of the areas covered in oral presentation during the conference, and reports on some of the notable major new findings described at this 2009 World Congress of Psychiatric Genetics.
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The genetics of obsessive-compulsive disorder and Tourette syndrome: an epidemiological and pathway-based approach for gene discovery. J Am Acad Child Adolesc Psychiatry 2010; 49:810-9, 819.e1-2. [PMID: 20643314 DOI: 10.1016/j.jaac.2010.04.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Revised: 04/27/2010] [Accepted: 04/28/2010] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To provide a contemporary perspective on genetic discovery methods applied to obsessive-compulsive disorder (OCD) and Tourette syndrome (TS). METHOD A review of research trends in genetics research in OCD and TS is conducted, with emphasis on novel approaches. RESULTS Genome-wide association studies (GWAS) are now in progress in OCD and TS and will provide a platform for future discovery of common gene variants. Optimally, newer next-generation genome sequencing methods can also be used to detect larger effect genes (rare gene variants), taking advantage of pedigrees. Studies of gene networks or sets rather than individual genes will be required to elucidate biological etiology, as neural systems appear to act redundantly. Newer phenotyping strategies, such as symptom-based subtypes, cross-disorder latent class types, and intermediate phenotypes (endophenotypes) will need to be developed and tested to better align clinical and physiological measures with genetic architecture. CONCLUSION Although genetics research has made significant advances based on computational strength and bioinformatics advances, newer approaches to phenotyping and judicious study of gene etiological networks will be needed to uncover the genetic etiology of OCD and TS.
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Rickards H, Woolf I, Cavanna AE. “Trousseau's disease:” A description of the gilles de la tourette syndrome 12 years before 1885. Mov Disord 2010; 25:2285-9. [DOI: 10.1002/mds.23202] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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O’Rourke JA, Scharf JM, Yu D, Pauls DL. The genetics of Tourette syndrome: a review. J Psychosom Res 2009; 67:533-45. [PMID: 19913658 PMCID: PMC2778609 DOI: 10.1016/j.jpsychores.2009.06.006] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 06/23/2009] [Accepted: 06/26/2009] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This article summarizes and evaluates recent advances in the genetics of Gilles de la Tourette syndrome (GTS). METHODS This is a review of recent literature focusing on (1) the genetic etiology of GTS; (2) common genetic components of GTS, attention deficit hyperactivity disorder (ADHD), and obsessive compulsive disorder (OCD); (3) recent linkage studies of GTS; (4) chromosomal translocations in GTS; and (5) candidate gene studies. RESULTS Family, twin, and segregation studies provide strong evidence for the genetic nature of GTS. GTS is a heterogeneous disorder with complex inheritance patterns and phenotypic manifestations. Family studies of GTS and OCD indicate that an early-onset form of OCD is likely to share common genetic factors with GTS. While there apparently is an etiological relationship between GTS and ADHD, it appears that the common form of ADHD does not share genetic factors with GTS. The largest genome wide linkage study to date observed evidence for linkage on chromosome 2p23.2 (P=3.8x10(-5)). No causative candidate genes have been identified, and recent studies suggest that the newly identified candidate gene SLITRK1 is not a significant risk gene for the majority of individuals with GTS. CONCLUSION The genetics of GTS are complex and not well understood. The Genome Wide Association Study (GWAS) design can hopefully overcome the limitations of linkage and candidate gene studies. However, large-scale collaborations are needed to provide enough power to utilize the GWAS design for discovery of causative mutations. Knowledge of susceptibility mutations and biological pathways involved should eventually lead to new treatment paradigms for GTS.
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Eddy CM, Rizzo R, Cavanna AE. Neuropsychological aspects of Tourette syndrome: a review. J Psychosom Res 2009; 67:503-13. [PMID: 19913655 DOI: 10.1016/j.jpsychores.2009.08.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 07/08/2009] [Accepted: 08/06/2009] [Indexed: 11/16/2022]
Abstract
Tourette syndrome (TS) is assumed to result from frontostriatal dysfunction, which would be expected to result in impairments in neuropsychological functions. This possibility has been explored in a number of studies that have assessed the performance of patients with TS within major cognitive domains and on tests involving executive functioning. We aim to summarize the main findings of these studies while evaluating the influence of task limitations and potentially critical confounding factors such as the presence of comorbidity. Although there is clearly a need for improved study design, we tentatively suggest that there is considerable evidence for cognitive impairment in a subgroup of patients, and that some difficulties seem to be intrinsic to TS. These impairments may reflect dysfunction of the anterior cingulate network within the frontostriatal pathway.
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Affiliation(s)
- Clare M Eddy
- Department of Psychology, University of Birmingham, Birmingham, UK
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Grados MA, Mathews CA. Clinical phenomenology and phenotype variability in Tourette syndrome. J Psychosom Res 2009; 67:491-6. [PMID: 19913653 DOI: 10.1016/j.jpsychores.2009.07.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 07/14/2009] [Accepted: 07/14/2009] [Indexed: 10/20/2022]
Abstract
Tourette syndrome (TS) is a neurodevelopmental disorder with a rich phenomenology that includes simple and complex motor and vocal tics as well as multiple comorbidities. From a nosological perspective, it is evident that a continuum of tic severity exists, of which TS is the most severe and rare form, while transient tics and chronic tics represent milder forms. From a psychopathology perspective, TS is often concurrent with obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD); these disorders appear to define TS "types" TS only, TS+OCD, and TS+OCD+ADHD. Additional clinical aspects of TS include more frequent than expected occurrence of anger episodes, anxiety disorders, mood disorders, impulse control disorders, learning disorders, and pervasive developmental disorders. Data reduction techniques have been used more recently to define a "simple" and "complex" tic symptom clusters or factors. Phenomenologic approaches can be used in TS to guide future pathophysiologic research.
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Affiliation(s)
- Marco A Grados
- Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Robertson MM, Eapen V, Cavanna AE. The international prevalence, epidemiology, and clinical phenomenology of Tourette syndrome: a cross-cultural perspective. J Psychosom Res 2009; 67:475-83. [PMID: 19913651 DOI: 10.1016/j.jpsychores.2009.07.010] [Citation(s) in RCA: 174] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Revised: 07/13/2009] [Accepted: 07/14/2009] [Indexed: 10/20/2022]
Abstract
The overall international prevalence of Tourette syndrome (TS) is 1% in the majority of cultures of the world. Both TS and tics are certainly more obvious and may be more common in younger people. Moreover, TS is seen less frequently in some cultures. However, in all cultures where it has been reported, the phenomenology is similar, highlighting the biological underpinnings of the disorder. This article reviews the international prevalence, epidemiology, and clinical phenomenology of TS, from a cross-cultural perspective.
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Haddad ADM, Umoh G, Bhatia V, Robertson MM. Adults with Tourette's syndrome with and without attention deficit hyperactivity disorder. Acta Psychiatr Scand 2009; 120:299-307. [PMID: 19486328 DOI: 10.1111/j.1600-0447.2009.01398.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Comorbidity between Tourette's syndrome (TS) and attention deficit hyperactivity disorder (ADHD) is high. In children, those with both TS+ADHD fare less well than those with TS-only on measures of both psychopathology and behaviour. The objective of this study was to document such measures in adult patients. METHOD Eighty adults with TS-only were compared to 64 with TS+ADHD using a clinical interview and standardised measures of depression, anxiety and obsessionality. RESULTS The two groups were no different on measures of TS severity. TS+ADHD patients had significantly more depression, anxiety, obsessive-compulsive behaviour and maladaptive behaviours than patients with TS-only. There were also significant differences in the incidence of copro- and echo-phenomena and family history of ADHD. CONCLUSION The finding of increased overall behavioural difficulties and psychopathology in adult patients with TS+ADHD when compared with TS-only is in agreement with previous findings in children with TS. Appropriate treatment of ADHD in TS patients during childhood may prevent many behavioural problems in adulthood.
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Affiliation(s)
- A D M Haddad
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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Albin RL, Koeppe RA, Wernette K, Zhuang W, Nichols T, Kilbourn MR, Frey KA. Striatal [11C]dihydrotetrabenazine and [11C]methylphenidate binding in Tourette syndrome. Neurology 2009; 72:1390-6. [PMID: 19380698 DOI: 10.1212/wnl.0b013e3181a187dd] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Tourette syndrome (TS) is a common neurodevelopmental disorder marked by tics and behavioral comorbidities. Clinical pharmacology suggests that dopaminergic signaling abnormalities are part of the pathophysiology of TS. Prior molecular imaging studies of nigrostriatal dopaminergic terminal markers report conflicting results. Our goal was to characterize the distribution of nigrostriatal dopaminergic terminals in subjects with TS. METHODS Thirty-three adult subjects with TS were studied with PET using [11C]dihydrotetrabenazine (DTBZ), a ligand for the type 2 vesicular monoamine transporter, and with [11C] methylphenidate (MP), a ligand for the plasmalemmal dopamine transporter. Subjects were characterized with standard rating instruments for tic severity, obsessive-compulsive behaviors, and attentional deficits. RESULTS We found no differences between subjects with TS and control subjects in DTBZ and MP binding in any striatal region. There was no correlation between binding measures and clinical variables. Ventral striatal DTBZ and MP binding distributions in subjects with TS were normal. CONCLUSIONS We found no evidence of increased striatal dopaminergic innervation in Tourette syndrome (TS). Discrepancy between our present results and those of other studies may be explained by heterogeneity of TS.
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Affiliation(s)
- R L Albin
- Geriatrics Research, Education, and Clinical Center, Ann Arbor VAMC, Ann Arbor, MI, USA.
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Robertson MM. The prevalence and epidemiology of Gilles de la Tourette syndrome. Part 2: tentative explanations for differing prevalence figures in GTS, including the possible effects of psychopathology, aetiology, cultural differences, and differing phenotypes. J Psychosom Res 2008; 65:473-86. [PMID: 18940378 DOI: 10.1016/j.jpsychores.2008.03.007] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 03/11/2008] [Accepted: 03/11/2008] [Indexed: 01/01/2023]
Abstract
As has been demonstrated, Gilles de la Tourette Syndrome (GTS) occurs in at least 1% of the population worldwide. However, earlier studies suggested a lower prevalence. In addition, the prevalence figures for different studies very between 0.4% and 3.8%. Moreover, the prevalence appears to vary in some parts of the world and races, with a lower rate in Afro-Americans and sub-Saharan black Africans. In this the second part of the review, possible reasons for the differences in prevalence and epidemiology are discussed. Tentative explanations for differing prevalence figures in GTS include problems with the diagnosis of GTS, the multidimensional nature of tics, as well as other tic factors including the waxing and waning of symptoms and the suppressibility of symptoms. Other factors inherent to GTS include the fact that there is no diagnostic test and indeed no definitive diagnosis other than clinical, the fact that psychosocial stresses can lead to increased tic severity, and that comorbid disorders may mask tics. The varying methods of study employed can also effect prevalence. There may be some regional differences in GTS as well, which may be due to a lack of awareness of GTS, or it may be a true reflection of low prevalence as in some populations GTS does appear rare. With regard to the sub-Saharan Africa data and possibly the African American data, matters are much more complex than meets the eye. The following reasons are all possible for the apparent rarity in these populations and include (i) other medical priorities and less propensity to seek health care, (ii) lack of awareness of GTS, (iii) chance, (iv) ethnic and epigenetic differences and reasons, (v) genetic and allelic differences in different races, and (vi) an admixture of races. The aetiology of GTS is also complex, with influences from complex genetic mechanisms, pre- and perinatal difficulties and, in a subgroup, some infections, possibly by epigenetic mechanisms. These may well affect phenotype and, thus, prevalence. There have even been suggestions that people with GTS are increasing. Recent data suggests that GTS is not a unitary condition and that there may well be different types of GTS. The prevalence of GTS in these individual subtypes is unknown. It is suggested that a new nomenclature be adopted for GTS in future, pending further genetic and phenomenological studies. To what extent the aetiology affects the phenotype and, thus, the prevalence is still unclear.
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