Internet Mental Health

TOURETTE'S DISORDER






(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Abnormal or Red)

Expanded Quality of Life Scale For Tourette's Disorder

Internet Mental Health Quality of Life Scale

  • Onset before age 18 of both multiple motor and one or more vocal tics. (A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.)

  • Tics persist for more than 1 year.

  • Tics are not due to substance use (e.g., cocaine) or another medical condition (e.g., Huntington's disease, postviral encephalitis).

Prediction

    Onset is usually between ages 4-6. Peak severity occurs usually between ages 10-12, with a decline in severity during adolescence. Tics usually decrease during adulthood, but a small minority of individuals will have persistently severe or worsening symptoms in adulthood. Tics fluctuate in severity and change in affected muscle groups and vocalizations over time.

Problems

    Occupational-Economic Problems:

    • Impairment ranges from none to severe.

    • Younger children may be unaware of their tics, and have no distress or impairment.

    • Functioning may be impaired by rejection by others or anxiety about having tics in public.

    Easily Distracted (Cognitive Impairment):

    • Attention-Deficit/Hyperactivity Disorder often co-occurs, and may be associated with disruptive behavior, impulsiveness, and/or social immaturity.

    Distressed, Easily Upset (Negative Emotion):

    • Tics cause social discomfort, shame, self-consciousness, demoralization, sadness.

    • Obsessive-Compulsive Disorder often co-occurs.

    Medical:
    • Multiple motor tics and 1 or more vocal tics.

    • Less than 10% have coprolalia (involuntary swearing).

    • Tic can cause physical injury.

    • Stimulants used in the treatment of Attention-Deficit/Hyperactivity can sometimes worsen the tics, and other times decrease the tics.



Explanation Of Terms And Symbols


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Combined Vocal and Multiple Motor Tic Disorder [de la Tourette] F95.2 - ICD10 Description, World Health Organization

A form of tic disorder in which there are, or have been, multiple motor tics and one or more vocal tics, although these need not have occurred concurrently. The disorder usually worsens during adolescence and tends to persist into adult life. The vocal tics are often multiple with explosive repetitive vocalizations, throat-clearing, and grunting, and there may be the use of obscene words or phrases. Sometimes there is associated gestural echopraxia which may also be of an obscene nature (copropraxia).
Tourette's Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with Tourette's disorder needs to meet all of the following criteria:

  • Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.)

  • The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.

  • Onset is before age 18 years.

  • The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington's disease, postviral encephalitis).


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Diagnostic Features

This disorder is characterized by both multiple motor and one or more vocal tics that have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.) Usually the tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year. Tics are generally experienced as involuntary but can be voluntarily suppressed for varying lengths of time. The onset is before age 18 years. By early adulthood, only approximately 20% of patients will still have moderately debilitating tics, with most having mild tics or even remittance of their symptoms. This disorder is not due to a drug, medication or general medical condition. It is very important to educate teachers, family, and peers regarding the symptoms and natural course of this disorder. Obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD) frequently accompany this disorder, and require treatment in addition to the tic management.

Prevalence

Tics are common in childhood but transient in most cases. The prevalence of Tourette's disorder in the USA is 3 per 1,000. The male to female ratio varies from 2:1 to 4:1.

Comorbidity

Children with this disorder often experience attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and separation anxiety disorder. Whereas adults with this disorder are more likely to experience major depressive disorder, substance use disorder, or bipolar disorder.

Effective Therapies

First-line treatment for mild-to-moderate tics is with an alpha-2 agonist (e.g., clonidine and guanfacine) or a benzodiazepine (e.g., clonazepam). OnabotulinumtoxinA (formerly known as botulinum toxin type A) injections may be considered when first-line treatment fails to improve mild-to-moderate tics. Individuals with severe tics that are refractory to first- and second-line therapy should be treated with neuroleptics or tetrabenazine. Out of the neuroleptics, risperidone is the preferable choice, followed by aripiprazole, ziprasidone, olanzapine, quetiapine, and the typical neuroleptics haloperidol and pimozide. Associated ADHD can effectively be treated with low-dose CNS stimulants (dextroamphetamine, levoamphetamine, and methylphenidate), or alpha-adrenergic agents (clonidine and guanfacine). Unfortunately, CNS stimulants sometimes increase tic disorder. Cognitive behavioral therapy (CBT) [exposure and response prevention] is a first-line treatment for any associated OCD. Second-line treatments for associated OCD are SSRI antidepressants and clomipramine. Medications can be tapered when the patient is experiencing fewer symptoms (e.g., on summer vacation).

Ineffective therapies

Vitamins and dietary supplements are ineffective for this disorder.

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Videos

  • Tourette Syndrome - Google
  • Tourette Syndrome In Childhood - Child Mind Institute
  • Tourette Syndrome Fact Sheet - National Institute of Neurological Disorders and Stroke
  • Tourette syndrome - Epocrates Online
  • Gilles de la Tourette syndrome - PubMed Health
  • Tourette Syndrome - Wikipedia
  • What is Tourette Syndrome? - Tourette's Syndrome Foundation of Canada
  • Clinical course of Tourette syndrome. - Tics typically have an onset between the ages of 4 and 6 years and reach their worst-ever severity between the ages of 10 and 12 years. On average, tic severity declines during adolescence. By early adulthood, roughly three-quarters of children with Tourette Syndrome (TS) will have greatly diminished tic symptoms and over one-third will be tic free. Comorbid conditions, such as OCD and other anxiety and depressive disorders, are more common during the adolescence and early adulthood of individuals with TS than in the general population. Although tics are the sine qua non of TS, they are often not the most enduring or impairing symptoms in children with TS. Measures used to enhance self-esteem, such as encouraging strong friendships and the exploration of interests, are crucial to ensuring positive adulthood outcome in TS.

Stories


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  • Tourette Syndrome Treatments - Centers For Disease Control And Prevention
  • Cognitive Behavioural Intervention For Tics - Tourette's Syndrome Foundation of Canada
  • Tourette syndrome. (2012) - Tourette syndrome (TS) is a neurodevelopmental disorder consisting of multiple motor and one or more vocal/phonic tics. TS is increasingly recognized as a common neuropsychiatric disorder usually diagnosed in early childhood and comorbid neuropsychiatric disorders occur in approximately 90% of patients, with attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) being the most common ones. Moreover, a high prevalence of depression and personality disorders has been reported. Although the mainstream of tic management is represented by pharmacotherapy, different kinds of psychotherapy, along with neurosurgical interventions (especially deep brain stimulation, DBS) play a major role in the treatment of TS. The current diagnostic systems have dictated that TS is a unitary condition. However, recent studies have demonstrated that there may be more than one TS phenotype. In conclusion, it appears that TS probably should no longer be considered merely a motor disorder and, most importantly, that TS is no longer a unitary condition, as it was previously thought.
  • Tourette syndrome: evolving concepts. (2011) - Tourette syndrome is a common childhood-onset neurobehavioral disorder characterized by multiple motor and phonic tics affecting boys more frequently than girls. Premonitory sensory urges prior to tic execution are common, and this phenomenon helps to distinguish tics from other hyperkinetic movement disorders. Tourette syndrome is commonly associated with attention deficit hyperactivity disorder, obsessive-compulsive disorder, learning difficulties, and impulse control disorder. The pathophysiology of this complex disorder is not well understood. Involvement of basal ganglia-related circuits and dopaminergic system has been suggested by various imaging and postmortem studies. Although it is considered a genetic disorder, possibly modified by environmental factors, an intense search has thus far failed to find causative genes. Symptomatic treatment of tics chiefly utilizes various alpha adrenergic agonists, antidopaminergic drugs, topiramate, botulinum toxin, and deep brain stimulation. Habit reversal therapy and other behavioral approaches may be a reasonable option for some cases.


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Improving Positive Behavior

Philosophers for the past 2,500 years have taught that it is very beneficial to start the day with goal-setting, and end the day with a brief review.

This habit of planning the day in the morning, then assessing these plans in the evening has been shown to increase health and happiness. There is an additional benefit from doing a weekly review of your life satisfaction.

Note: When each of the following videos finishes; you must exit YouTube (by manually closing the window) in order to return to this webpage.



International Space Station (For Meditation)



Planning My Day (5-Minute Meditation Video)

Planning My Day (Picture)



Reviewing My Day Or Week (5-Minute Meditation Video)



Life Satisfaction Scale (Video)



Healthy Social Behaviors Scale (Video)



Mental Health Scale (Video)

Why We All Need to Practice Emotional First Aid



The Philosophy Of Stoicism (5 minute video)

Stoicism 101 (52 minute video)



The Roman emperor and Stoic philosopher Marcus Aurelius ruled from 161 to 180 A.D.

An Example Of Mindfulness Meditation (10 minute video)

In the 5th century BCE, Buddha spent 6 years of his life mastering mindfulness meditation. He then decided to look beyond meditation. Buddha concluded that simply emptying the mind of thought is calming, but otherwise it accomplishes little - since "You return to the same world". Instead, Buddha taught that we should change our world by seeking enlightenment through practicing compassion, and living a calm, peaceful, happy life.



7-Minute Workout Is All You Need To Get Back Into Physical Shape


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  • The best summary on bad research is given by Laura Arnold in this Tedx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Criteria For High Quality Research Studies

  • It is imperative that medical researchers conduct high quality research studies, otherwise the US Food and Drug Administration (FDA) refuses to licence their new drug or therapy. In 2009, the cost of successfully licensing one new drug or therapy under the FDA scheme was estimated to be US$1,000 million. Thus psychiatric research which leads to FDA approval of a new drug or therapy has to be of the highest quality; however the majority of psychological research studies on new therapies fail to reach these high standards for research. This could explain why two-thirds of psychological research studies can't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible for a (normally distributed) strictly positive variable (because the "cooked" M and SD would mathematically require the strictly positive variable's range of data to include negative numbers). For a normally distributed sample of size of 25-70, this occurs when the SD is greater than one-half of the M; for a sample size of 70+, this occurs when the SD is greater than one-third of the M [using these formulas].

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes


  • Cochrane Reviews (the best evidence-based, standardized reviews available)

Research Topics

Tourette's Disorder - Latest Research (2016-2017)


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Internet Mental Health © 1995-2017 Phillip W. Long, M.D.