Profile of patients with essential blepharospasm and hemifacial spasm in the two largest ophthalmology reference centers in Brazil

PURPOSE

Information is scarce regarding the comprehensive profile of patients with essential blepharospasm and hemifacial spasm in Brazil. The present study aimed to assess the clinical features of patients with these conditions, followed up in two reference centers in Brazil.

METHODS

The study included patients with essential blepharospasm and hemifacial spasm, followed up at the Departments of Ophthalmology at Universidade Federal de São Paulo and Universidade de São Paulo. Apart from demographic and clinical features, past stressful events related to the first symptoms (triggering event), aggravating factors, sensory tricks, and other ameliorating factors for the eyelid spasms were assessed.

RESULTS

A total of 102 patients were included in this study. Most patients were female (67.7%). Essential blepharospasm was the most frequent movement disorder [51/102 patients (50%)], followed by hemifacial spasm (45%) and Meige's syndrome (5%). In 63.5% of the patients, the onset of the disorder was associated with a past stressful event. Ameliorating factors were reported by 76.5% of patients; 47% of patients reported sensory tricks. In addition, 87% of the patients reported the presence of an aggravating factor for the spasms; stress (51%) was the most frequent.

CONCLUSION

Our study provides information regarding the clinical features of patients treated in the two largest ophthalmology reference centers in Brazil.

Epidemiology of benign essential blepharospasm: A nationwide population-based retrospective study in Taiwan

IMPORTANCE

This study provides a nationwide, population-based data on the incidence of benign essential blepharospasm in Asian adults.

BACKGROUND

To describe the incidence, patient demographics, and risk factors associated with benign essential blepharospasm.

DESIGN

Population-based retrospective study.

PARTICIPANTS AND SAMPLES

A total of 1325 patients with benign essential blepharospasm were identified.

METHODS

Patients with diagnosis of blepharopsasm between January 2000 and December 2013 were sampled using the Longitudinal Health Insurance Database 2000. Secondary blepharospasm that may be related to neurological, trauma, and ocular surface disease were excluded.

MAIN OUTCOME MEASURED

Multivariate conditional logistic regression was used to estimate the odds ratios for potential risk factors of benign essential blepharospasm.

RESULTS

The mean annual incidence was 0.10‰ (0.07‰ for males, and 0.12‰ for females). The peak incidence was in the 50 to 59-year-old age group (0.19‰). People living in urban regions have more risk of developing blepharospasm comparing to people living in less urban regions (p <0.01). White-collar workers also have higher chance of having blepharospasm (p<0.001). Significant difference between control group and case group in hyperlipidemia (p <0.001), sleep disorders (p <0.001), mental disorders (depression, anxiety, obsessive compulsive disorder) (p <0.001), dry eye-related diseases (dry eye, Sjögren's syndrome) (p <0.001), Parkinson's disease (p <0.004), and rosacea (p <0.021) were also identified.

CONCLUSIONS AND RELEVANCE

Higher level of urbanization, white-collar work, sleep disorders, mental health diseases, dry eye-related diseases, Parkinsonism, and rosacea are possible risk factors for benign essential blepharospasm.

In vivo confocal microscopy of meibomian glands in primary blepharospasm: A prospective case-control study in a Chinese population

The aim of the study was to evaluate the morphological changes of meibomian glands (MGs) in primary blepharospasm (PBS) by in vivo laser scanning confocal microscopy (LSCM) and to investigate the correlations between clinical data of PBS and LSCM parameters of MGs. This prospective and case-control study recruited 30 consecutive PBS patients and 30 age- and gender-matched healthy controls. After questionnaire assessments of ocular surface disease index (OSDI), Jankovic rating scale, and blepharospasm disability index, all subjects underwent blink rate evaluation, tear film break-up time (TBUT), corneal fluorescein staining (CFS), Schirmer test, MG expressibility, meibum quality, MG dropout, and LSCM examination of the MGs. The main LSCM outcomes included the mean MG acinar area and density, orifice diameter, meibum secretion reflectivity, acinar irregularity, and inhomogeneity of interstice and acinar wall. The PBS patients had significantly higher blink rate, higher OSDI and CFS scores, lower TBUT and Schirmer test value, and worse MG expressibility than the controls (All P < 0.05), whereas meibum quality showed no difference (P > 0.05). The PBS patients showed lower values of MG acinar area, orifice diameter and meibum secretion reflectivity, and higher scores of acinar irregularity and inhomogeneity of interstices than the controls (All P < 0.05). For the PBS patients, the severity of blepharospasm evaluated by JCR scale was strong correlated with MG acinar area (P < 0.001), orifice diameter (P = 0.002), meibum secretion reflectivity (P = 0.002), and MG acinar irregularity (P = 0.013). The MG expressibility was significantly correlated to MG acinar area (P = 0.039), orifice diameter (P < 0.001), and MG acinar irregularity (P = 0.014). The OSDI score was moderate correlated with MG acinar irregularity (P = 0.016), whereas the TBUT value was positively correlated with MG acinar area (P = 0.045) and negatively correlated to MG acinar irregularity (P = 0.016). The CFS score was negatively correlated to MG orifice diameter (P = 0.008). The LSCM provided a noninvasive tool for in vivo histopathologic studies of MGs in PBS patients. The excessive constriction of lid muscles closely related to MG morphological alterations of PBS, which offered a new research approach to interpret the interactional mechanism between dry eye and PBS.

Speech-induced blepharospasm

Primary blepharospasm is an adult-onset dystonia typically present at rest and exacerbated by bright light, stress and voluntary movements of eyes and eyelids. Inconsistency or inducibility by activities involving muscles other than orbicularis oculi muscles are considered incongruous with typical primary blepharospasm, heralding the suspicion of psychogenicity. We report the clinical vignette of two patients manifesting an unusual presentation of primary blepharospasm, specifically triggered by voiced speech and associated with an otherwise 'typical' presentation of primary adult-onset dystonia in the lower face, larynx or upper limb. Speech-induced primary blepharospasm seems a rare occurrence, representing 1.3% of our clinic-based series of 149 patients with primary adult-onset primary blepharospasm. In these atypical patients, the feature of speech inducibility suggests that the abnormal surrounding inhibition between cortical subregions representing laryngeal and orbicularis oculi muscles might underlie dystonic overflow to the orbicularis oculi muscles following the voiced speech.

[Efficacy and side-effects of the botulinum toxin A treatment in patients with focal dystonia]

An aim of the study was to determine side-effects of disport, the botulinum toxin A (BTA), in the treatment of patients with spasmodic torticollis (ST) and blepharospasm (BS). More than 800 injections of BTA to patients with ST and 110 - to patients with BS have been performed for 6-years period. Side-effects are specified as follows: 1) autonomic reactions observed in women with increased anxiety and signs of autonomic dysfunction (47,5%) patients with ST), with most marked symptoms in the first injection and their further decreasing; 2) local side-effects related with errors in dose adjustment, injection technique (37,3% patients with ST and 59,5% patients with BS); 3) the smallest group of side-effects not related to the doctor's experience and adequate psychological preparation of the patient for manipulation (myasthenia-myopathia syndrome after the BTA therapy).

Update on blepharospasm: report from the BEBRF International Workshop

This review updates understanding and research on blepharospasm, a subtype of focal dystonia. Topics covered include clinical aspects, pathology, pathophysiology, animal models, dry eye, photophobia, epidemiology, genetics, and treatment. Blepharospasm should be differentiated from apraxia of eyelid opening. New insights into pathology and pathophysiology are derived from different types of imaging, including magnetic resonance studies. Physiologic studies indicate increased plasticity and trigeminal sensitization. While botulinum neurotoxin injections are the mainstay of therapy, other therapies are on the horizon.

Morphometric changes of sensorimotor structures in focal dystonia

Idiopathic cervical dystonia (CD) and benign essential blepharospasm (BEB) are the most common forms of focal dystonia. Previous autopsy and imaging studies suggested that these disorders are not accompanied by structural brain abnormalities. However, recent brain voxel-based morphometry (VBM) studies of these conditions suggest that there actually may be changes in gray matter. The objective of this stdy was to detect possible gray matter abnormalities in patients with CD and BEB using VBM and to compare the results between the two conditions and with age- and gender-matched controls. High-resolution MRI was employed to evaluate healthy controls and individuals with BEB and CD. Eleven BEB, 9 CD, and 14 healthy control subjects were imaged. VBM revealed alterations of gray matter structures involved in sensorimotor processing in the individuals with focal dystonia. In CD subjects there was increased gray matter in the thalamus, caudate head bilaterally, superior temporal lobe, and left cerebellum, while gray matter was decreased in the putamen bilaterally. BEB subjects had increased gray matter in the caudate head and cerebellum bilaterally as well as decrease in the putamen and thalamus bilaterally. These findings strongly underline the recent notion that idiopathic focal dystonias might have a detectable structural correlate. They also demonstrate structural similarities of the investigated focal dystonias, possibly reflecting a shared common pathophysiological origin.

Influence of coffee drinking and cigarette smoking on the risk of primary late onset blepharospasm: evidence from a multicentre case control study

Prior coffee and smoking habits were investigated in a multicentre case control study involving 166 patients presenting with primary late onset blepharospasm (BSP), 228 hospital control patients with primary hemifacial spasm and 187 population control subjects from five Italian centres. Information on age at disease onset, smoking and coffee drinking status at the reference age and average number of cups of coffee drunk/cigarettes smoked per day reached high and similar test-retest reproducibility in case and control patients. Unadjusted logistic regression analysis yielded a significant inverse association of prior coffee drinking and cigarette smoking with case status for the control groups. After adjustment for age, sex, referral centre, disease duration, years of schooling and ever coffee drinking/cigarette smoking, as appropriate, the smoking estimate lacked significance whereas the association of coffee intake and BSP did not (cases vs hospital control patients: OR 0.37 (95% CI 0.20 to 0.67); cases vs population control subjects: OR 0.44 (95% CI 0.23 to 0.85)). The strength of the inverse association between BSP and coffee intake tended to increase with the average number of cups drunk per day. There was a significant correlation between age of BSP onset and number of cups per day (adjusted regression coefficient 1.73; p = 0.001) whereas no correlation was found with number of packs of cigarettes per day. Coffee drinking may be inversely associated with the development of primary BSP and this association may partly depend on the amount consumed.

Epidemiology of primary focal dystonias in the western area of Tottori prefecture in Japan: Comparison with prevalence evaluated in 1993

An epidemiological survey of primary focal dystonias in the western area of Tottori Prefecture in Japan was conducted in 2003, and the results were compared with those of a previous survey in 1993. The service-based prevalence of primary focal dystonia was 13.7 per 100,000 population, representing an increase from that found in the 1993 survey. In 1997, botulinum toxin type A was approved for use in Japan to treat blepharospasm, and the increased number of patients now being evaluated and diagnosed with focal dystonias at medical centers throughout Japan may be responsible for this increased prevalence. Prevalence by subtype per 100,000 population was as follows: facial dystonia, 6.5; spasmodic torticollis, 2.0; writer's cramp, 4.4; and other focal dystonias; 0.8. Facial dystonia showed the most marked increase in service-based prevalence among these subtypes.

Are nongenetic triggers for dystonia type-specific? A study exploring scoliosis in blepharospasm

We previously observed that diseases of the anterior ocular segment predispose to primary blepharospasm, but not to other focal dystonias. In this multicenter study, we tested whether prior scoliosis, which increases the risk of developing cervical dystonia, is also a predisposing factor to blepharospasm. The frequency of scoliosis did not differ between blepharospasm patients and controls. This finding supports the hypothesis that environmental risk factors may be specific for a single form of adult-onset dystonia.

Prevalence of primary blepharospasm in Sardinia, Italy: A service-based survey

We performed a service-based epidemiological study of primary blepharospasm in the island of Sardinia (Italy). Due to its favorable geographical location, we are confident we will provide reliable data from patients seeking botulinum toxin treatment. A total of 53 patients were assessed. Prevalence was estimated to be 32.2 per 1 million (95% confidence interval, 23.0-40.8). These results are in line with those obtained in other similar surveys, that is, record-based, and performed in various European regions such as Northern England, the Munich area, as well as the Epidemiologic Study of Dystonia in Europe.

Benign Essential Blepharospasm: Risk Factors with Reference to Hemifacial Spasm

BACKGROUND

To identify risk factors associated with benign essential blepharospasm (BEB) with reference to hemifacial spasm (HFS). Persons with BEB and HFS experience similar physical symptoms, yet the two disorders have different etiologies.

METHODS

Patients with BEB (n = 159) or HFS (n = 91) were identified from two large neuro-ophthalmology clinics. Demographic, medical, behavioral, and psychological characteristics were obtained from chart review and a telephonic survey questionnaire.

RESULTS

The average age of BEB and HFS was 66 years. Most patients in both groups were retired, white, and female. BEB patients were more than two times as likely to meet the diagnostic criteria for generalized anxiety disorder than HFS patients (odds ratio, 2.13; 95% confidence interval, 1.22-3.72). There was no difference between the two groups regarding demographics, smoking, a family history of dystonia, Parkinson disease, Bell palsy, Tourette disorder, obsessive compulsive symptoms, history of head trauma, alcohol use, or caffeine consumption.

CONCLUSIONS

As compared to HFS, BEB was significantly more often associated with generalized anxiety disorder. Given the similarity of other clinical features of these two disorders, it is reasonable to conclude that anxiety is a cause not a consequence of BEB. Contrary to previous studies, BEB was not associated with obsessive-compulsive symptoms, head trauma, Parkinson disease, Bell palsy, Tourette disorder, or lack of smoking.

[Dystonias: what the practitioner needs to know]

Dystonia is characterized by involuntary muscular contractions resulting in repetitive movements and/or postures, with co-contraction of antagonist muscle groups. the present overview describes the fundamentals of dystonic movement disorders, and provides information on their diagnosis and therapy, including in particular the not infrequent focal dystonias spasmodic torticollis, blepharospasm, and writer's cramp, and the generalized forms. For the practitioner it is of primary importance to be able to recognize these sometimes bizarre movement disorders as dystonias. In many cases, the correct diagnosis makes possible effective treatment that frequently results in an appreciable improvement in the patient's symptoms.

Benign essential blepharospasm among residents of Olmsted County, Minnesota, 1976 to 1995: an epidemiologic study

PURPOSE

To describe the incidence, patient demographics, and response to treatment of benign essential blepharospasm (BEB) in a population-based cohort.

METHODS

In this epidemiologic study, we searched the Rochester Epidemiology Project database for patients diagnosed with blepharospasm or related disorders between 1976 and 1995. The incident rate denominator was based on a linear interpolation of decennial census data from Olmsted County. The 95% confidence interval for the incidence rate was based on the Poisson distribution.

RESULTS

Olmsted County residents (n = 295) were diagnosed with blepharospasm or related disorders between 1976 and 1995. Of these, 8 patients met the criteria for BEB. The calculated incidence rate of BEB is 1.2 persons per 100,000 population per year (95% CI, 0.37 to 2.02). At the time of BEB diagnosis, the median patient age was 61.5 years, and symptoms had been present for a median of 24 months. Four patients were men and 4 were women. Four of the 8 patients had Meige syndrome. Three of 4 patients treated with oral medications reported symptomatic improvement. Botulinum toxin injection was offered to all patients, but only 4 elected treatment. All who were treated with botulinum toxin had temporary symptomatic improvement. No patient underwent surgical treatment for BEB. Two patients had resolution of symptoms within the follow-up period.

CONCLUSIONS

BEB is a rare disorder. In this small, population-based sample, women and men were affected with equal frequency, and half of patients had lower facial dystonia (Meige syndrome). Only half of patients with BEB elected botulinum toxin injections, and none required surgery. Disease remission occurred in 2 of 8 patients.

Menopause and menarche in patients with primary blepharospasm: an exploratory case-control study

We studied the relationships between blepharospasm (BSP) and menopause/menarche in female patients with primary BSP (n = 83) and age-matched healthy (n = 83) and disease controls (n = 83). BSP patients and matched controls had comparable age at menopause, and there was no correlation between age at menopause and age at BSP onset. Thus, menopause probably exerts no significant influence on the age-dependent development of BSP. BSP cases tended to have a later menarche than either group of controls. The association was independent of age, disease duration and education level. Because the higher the age at menarche, the higher the age at BSP onset, later menarche was unlikely to be a risk factor for BSP. Rather, the two conditions may share pathophysiologic mechanisms, for example minor abnormality of neurotransmitter systems controlling both the motor system and the maturation of the hypothalamic-pituitary-gonadal axis responsible for the onset of puberty.

Epidemiology of primary blepharospasm

We review epidemiological data on primary blepharospasm (BSP). There is a large variation in the stated prevalence of BSP, with crude estimates ranging from 16 to 133 per million in different studies. A large proportion of this variability may be the result of differences in physician education on BSP. Age and female gender may increase the risk of developing BSP. The few case-control studies focusing on adult dystonias including BSP showed an increased risk in association with family history of dystonia and/or postural tremor, prior head and face trauma, and prior eye disease (e.g., blepharitis and keratoconjunctivitis), and a decreased risk associated with cigarette smoking. No association was found with age-related medical conditions such as hypertension and diabetes, family history of parkinsonism, and a history of anxiety or depression. Broocks et al. [Am J Psychiatry, 1998;155:555-557] found a significantly higher frequency of obsessive-compulsive symptoms in BSP than hemifacial spasm despite the clinical similarity. Among putative risk factors for BSP, age at onset, female gender, and prior head or face trauma may affect spread of dystonia to adjacent body regions. While limited, the body of epidemiological data support the idea that environmental and familial, possibly genetic, factors may both be important in the etiology of BSP.

Blepharoclonus in multiple sclerosis

OBJECTIVE

Keane described 2 patients with gaze-evoked blepharoclonus (BLC), a form of reflex BLC, and multiple sclerosis (MS). A search for common areas of demyelination and focal axonal atrophy (T1 black holes) of the central nervous system (CNS) in 11 patients with MS exhibiting eyelid closure BLC was conducted employing magnetic resonance imaging (MRI). Finding lesions in common CNS locations on these patients can help to elucidate the pathogenesis of this restricted movement disorder.

MATERIALS AND METHODS

Eleven adult patients with relapsing-remitting, primary or secondary progressive MS were studied. MRI views were completed employing a 1.5-tesla scanner. Contrast Axial T1 imaging was obtained in 9 patients.

RESULTS

TL blackholes were not identified. Ten patients had multiple, scattered periventricular (PV) areas of demyelination. Four patients exhibited brainstem lesions of diverse but inconsistent locations including midbrain, cerebellar peduncle, pons and medulla. In 2 of the patients the brainstem lesions were transient but BLC persisted after the lesions regressed.

CONCLUSION

No common areas of CNS demyelination or focal axonal atrophy were identified on these patients with MS and BLC. The pathogenesis and clinical significance of BLC in MS remains to be elucidated.

Prevalence of primary blepharospasm in a community of Puglia region, Southern Italy

The authors ascertained the prevalence of primary blepharospasm (BSP) in a community located in Puglia, a region in Southern Italy, by focusing on neurologists and ophthalmologists. The crude prevalence rates were 133 per million (95% CI, 61--153) for both focal and segmental BSP, 74 per million (95% CI, 24--173) for focal BSP, and 59 per million (95% CI, 16--151) for segmental BSP. Prevalence rate increased with age. Apraxia of eyelid opening and BSP coexisted in one third of cases.

[Treatment of focal dystonia with botulinum toxin A]

Local injections with Botulinum toxin A (BtxA) are safe and effective in the treatment of focal dystonia. In cervical dystonia and blepharospasm, BtxA injections have become the treatment of choice. However, good results have also been reported with oromandibular dystonia, spasmodic dysphonia and writer's cramp. In cervical dystonia, muscles for injection are selected by clinical presentation or in complex forms with EMG guidance. Several studies have shown that 500 units Dysport are safe and effective in the treatment of cervical dystonia. In blepharospasm, injections are performed in the periorbital part of the orbicularis oculi muscle with good results for 12-14 weeks. The most frequently employed starting dose is 120 units Dysport per eye, divided in three periorbital injection sites. In case of levator inhibition, the pretarsal part of the orbicularis oculi muscle should be injected in a lower dose. EMG guidance is not necessary. By contrast, BtxA treatment of spasmodic dysphonia and writer's cramp require EMG-guided injections in order to avoid side-effects. Dose recommendations for the various types of dystonia are given in the text. In up to 5% of patients with dystonia, the development of neutralising antibodies is reported following repetitive injections with BtxA. Patients with antibodies had a shorter interval between injections, more "boosters", a higher dose per 3-month interval, and a higher total dose injected. In case of neutralizing antibodies against the A toxin, the treatment with Botulinum toxin B (Neurobloc) is a possible alternative.

Higher prevalence of obsessive-compulsive symptoms in patients with blepharospasm than in patients with hemifacial spasm

OBJECTIVE

The prevalences of obsessive-compulsive symptoms in patients suffering from blepharospasm and in those with hemifacial spasm were determined. The two conditions have similar symptoms, but only blepharospasm is etiologically linked to basal ganglia dysfunction.

METHOD

After being interviewed with the Structured Clinical Interview for DSM-III-R, 13 patients with blepharospasm and 13 with hemifacial spasm completed the SCL-90-R and the Hamburg Obsession/Compulsion Inventory-Short Form.

RESULTS

Patients in the blepharospasm group had significantly more obsessive-compulsive symptoms, as indicated by higher scores on the Hamburg Obsession/Compulsion Inventory-Short Form, than the patients with hemifacial spasm. SCL-90-R scores were in the normal range for nine and eight categories, respectively (out of nine).

CONCLUSIONS

The findings provide additional support for the hypothesis that obsessive-compulsive symptoms are related to basal ganglia dysfunction.

Dystonia in progressive supranuclear palsy

OBJECTIVES

To document the nature, distribution, and frequency of dystonic symptoms in progressive supranuclear palsy (PSP).

METHODS

Charts and videotapes of all clinically diagnosed patients with PSP seen between 1983 and 1993 were reviewed and the occurrence, nature, and distribution of all dystonic symptoms were recorded.

RESULTS

Of 83 identified cases 38 had some dystonic features. Twenty (24%) had blepharospasm (one was induced by levodopa), 22 (27%) had limb dystonia (one was induced by electroconvulsive therapy and another by levodopa), 14 (17%) had axial dystonia in extension, one had oromandibular dystonia induced by levodopa, and two had other cranial dystonias. Six patients had limb dystonia as an early or presenting feature, sometimes leading to misdiagnosis of cortical-basal ganglionic degeneration. All three patients who had postmortem confirmation of the diagnosis had other concurrent disease. One patient with bilateral limb dystonia and blepharospasm had evidence of previous hydrocephalus and severe arteriosclerotic changes. One with arm dystonia also had cerebrovascular disease and one with hemidystonia also had rare swollen chromatolytic neurons in the frontotemporal cortex.

CONCLUSIONS

Dystonia is a common manifestation of PSP. Limb dystonia is particularly common and may indicate the presence of concurrent disease. When dystonia occurs in PSP, dopaminergic medication should be cautiously reduced or discontinued to rule out the possibility of treatment induced symptoms.

Prevalence of focal dystonias in the western area of Tottori Prefecture in Japan

We evaluated the prevalence of focal dystonias in the western area of Tottori Prefecture in Japan. The population of the area was 244,935 on October 1, 1992. Because four patients with blepharospasm and three patients with writer's cramp did not visit any hospitals or clinics in 1993 and did not reply to our question letter, we could not confirm their present condition: with or without focal dystonia in 1993. Four patients with facial dystonia including blepharospasm and oromandibular dystonia, seven with spasmodic torticollis, and four with writer's cramp were observed. The prevalence of focal dystonias was 6.12 per 100,000 persons, which may be lower than that in western countries. Although the reasons for this difference are still unclear, a genetic factor may be one implication.

Genetic contribution to idiopathic adult-onset blepharospasm and cranial-cervical dystonia

A family study in 29 patients with idiopathic adult-onset blepharospasm (n = 16) and cranial-cervical dystonia (n = 13) was undertaken by examining 189 first-degree relatives. Six relatives with dystonia were identified in 6 families. A further 3 affected relatives, now deceased, were from 2 other families. All the secondary cases were parents or siblings. There was a tendency for affected relatives to have the same type of dystonia of index patients. To assess the significance of secondary cases we compare the incidence of affected siblings between probands and their spouses. Dystonia was found in 5 out of 120 proband siblings whereas none of the 142 spouse siblings was affected (p < 0.05). Segregation analysis suggested an autosomal-dominant transmission and reduced penetrance or, alternatively, polygenic inheritance.

An epidemiological study of tics

We devised a questionnaire for estimation of each tic, and used a two-step investigation procedure, first by a parent questionnaire with 1,218 responses and second by a confirmatory telephone interview for 197 positive responses. The average estimated values were 11.3% for boys and 5.2% for girls. The prevalences were--blinking: 4.2%, head-jerking: 1.6%, shrugging: 1.2%, mouth-twitching: 0.6%, face-distortion: 0.5%, mouth-opening: 0%, throat-clearing: 2.7%, sniffing: 0.6%, and vocalization: 0.2%. According to the criteria in DSM-III-R, 5.1% of 1,218 had TTD, 2.2% had CMVTD, and 0.5% had Tourette disorder.