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  • Mood, Anxiety Disorders Common in Tourette, at a Young Age

    Patients with Tourette Syndrome Likely To Have Additional Psychiatric Symptoms
    February 12, 2015

    dr-carol-mathews.jpeg Interview with:Carol Mathews
    Professor, Psychiatry
    UCSF School of Medicine

    Medical Research: What is the background for this study? What are the main findings?

    Dr. Mathews: The background for this study is that, as a part of ongoing genetic studies of Tourette Syndrome, the Tourette Syndrome Association International Genetics Collaborative (TSAICG) has collected a wealth of information about commonly co-occurring psychiatric disorders in individuals with Tourette Syndrome and their families, providing us with an opportunity to explore questions about Tourette Syndrome that are relevant to individuals with Tourette Syndrome, their families, and their treating clinicians.

    Medical Research: What should clinicians and patients take away from your report?

    Dr. Mathews: Individuals who present to clinics for evaluation and/or treatment of Tourette Syndrome are very likely to have additional psychiatric symptoms, including not only symptoms of obsessive compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD), but also mood, anxiety, and disruptive behavior disorders. These disorders start early in life, sometimes as early as age 4, in individuals with TS. None of the psychiatric conditions studied, except OCD and ADHD, had a direct genetic relationship to TS. Instead, they were related to OCD or ADHD. This suggests that individuals with OCD or ADHD, or those who have family members with these disorders, should be especially carefully screened for additional psychiatric symptoms.

    Clinicians should begin to screen early for psychiatric symptoms in individuals with TS, particularly if they have ADHD or OCD or a family history of these conditions.

    Medical Research: What recommendations do you have for future research as a result of this study?

    Dr. Mathews: Additional research needs to be done to further explore our preliminary finding that psychotic symptoms and substance abuse are not elevated in individuals with TS. The genetic causes and the genetic relationships of these disorders to each other are a major focus of our ongoing work.


    Hirschtritt ME, Lee PC, Pauls DL, et al. Lifetime Prevalence, Age of Risk, and Genetic Relationships of Comorbid Psychiatric Disorders in Tourette Syndrome. JAMA Psychiatry. Published online February 11, 2015. doi:10.1001/jamapsychiatry.2014.2650.
    TouretteLinks Forum

  • #2
    Re: Patients with Tourette Syndrome Likely To Have Additional Psychiatric Symptoms

    Lifetime Prevalence, Age of Risk, and Genetic Relationships of Comorbid Psychiatric Disorders in Tourette Syndrome

    Matthew E. Hirschtritt, MD, MPH1; Paul C. Lee, MD, MPH2; David L. Pauls, PhD2; Yves Dion, MD3; Marco A. Grados, MD4; Cornelia Illmann, PhD2; Robert A. King, MD5; Paul Sandor, MD6,7,8; William M. McMahon, MD9; Gholson J. Lyon, MD, PhD10; Danielle C. Cath, MD, PhD11,12; Roger Kurlan, MD13; Mary M. Robertson, MBChB, MD, DSc(Med), FRCP, FRCPCH, FRCPsych14,15,16; Lisa Osiecki, BA2; Jeremiah M. Scharf, MD, PhD2,17,18,19,20; Carol A. Mathews, MD1; for the Tourette Syndrome Association International Consortium for Genetics

    JAMA Psychiatry.
    Published online February 11, 2015.

    Importance Tourette syndrome (TS) is characterized by high rates of psychiatric comorbidity; however, few studies have fully characterized these comorbidities. Furthermore, most studies have included relatively few participants (<200), and none has examined the ages of highest risk for each TS-associated comorbidity or their etiologic relationship to TS.

    Objective To characterize the lifetime prevalence, clinical associations, ages of highest risk, and etiology of psychiatric comorbidity among individuals with TS.

    Design, Setting, and Participants Cross-sectional structured diagnostic interviews conducted between April 1, 1992, and December 31, 2008, of participants with TS (n = 1374) and TS-unaffected family members (n = 1142).

    Main Outcomes and Measures Lifetime prevalence of comorbid DSM-IV-TR disorders, their heritabilities, ages of maximal risk, and associations with symptom severity, age at onset, and parental psychiatric history.

    Results The lifetime prevalence of any psychiatric comorbidity among individuals with TS was 85.7%; 57.7% of the population had 2 or more psychiatric disorders. The mean (SD) number of lifetime comorbid diagnoses was 2.1 (1.6); the mean number was 0.9 (1.3) when obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD) were excluded, and 72.1% of the individuals met the criteria for OCD or ADHD. Other disorders, including mood, anxiety, and disruptive behavior, each occurred in approximately 30% of the participants. The age of greatest risk for the onset of most comorbid psychiatric disorders was between 4 and 10 years, with the exception of eating and substance use disorders, which began in adolescence (interquartile range, 15-19 years for both). Tourette syndrome was associated with increased risk of anxiety (odds ratio [OR], 1.4; 95% CI, 1.0-1.9; P = .04) and decreased risk of substance use disorders (OR, 0.6; 95% CI, 0.3-0.9; P = .02) independent from comorbid OCD and ADHD; however, high rates of mood disorders among participants with TS (29.8%) may be accounted for by comorbid OCD (OR, 3.7; 95% CI, 2.9-4.8; P < .001). Parental history of ADHD was associated with a higher burden of non-OCD, non-ADHD comorbid psychiatric disorders (OR, 1.86; 95% CI, 1.32-2.61; P < .001). Genetic correlations between TS and mood (RhoG, 0.47), anxiety (RhoG, 0.35), and disruptive behavior disorders (RhoG, 0.48), may be accounted for by ADHD and, for mood disorders, by OCD.

    Conclusions and Relevance This study is, to our knowledge, the most comprehensive of its kind. It confirms the belief that psychiatric comorbidities are common among individuals with TS, demonstrates that most comorbidities begin early in life, and indicates that certain comorbidities may be mediated by the presence of comorbid OCD or ADHD. In addition, genetic analyses suggest that some comorbidities may be more biologically related to OCD and/or ADHD rather than to TS.
    TouretteLinks Forum


    • #3
      Re: Patients with Tourette Syndrome Likely To Have Additional Psychiatric Symptoms

      OCD, ADHD most common psychiatric disorders in Tourette Syndrome
      Hirschtritt ME, et al. JAMA Psychiatry. 2015;doi:10.1001/jamapsychiatry.2014.2650.
      Healio Psychiatric Annals
      February 13, 2015

      The most common psychiatric comorbidities among those with Tourette Syndrome include obsessive compulsive disorder and attention-deficit/hyperactivity disorder, according to data reported in JAMA Psychiatry.

      “Our results have implications both clinically and for ongoing research into the causes and etiologic relationships between these psychiatric disorders,” the researchers wrote.

      They collected phenotypic data from genetic studies that included patients with Tourette Syndrome (n = 1,374; aged 6 years or older) and their unaffected parents and siblings (n = 1,142) between 1992 and 2008.

      Data indicate an 85.7% lifetime prevalence of any psychiatric comorbidity among individuals with Tourette Syndrome, and 57.7% of the population had two or more psychiatric disorders.

      The most common psychiatric conditions were OCD (50%) and ADHD (54.3%); 72.1% of those with Tourette Syndrome met the DSM-IV criteria for either disorder, according to researchers.

      Females were more likely to have OCD (57.1%) compared with males (47.5%; P < .01), according to data. However, males were more likely to have ADHD (58.5% vs. 42.3%), they wrote.

      Additional data indicated the high-risk period for onset began at age 4 years for anxiety disorders, age 7 years for mood disorders, and age 13 years for substance use and eating disorders.

      Patients with Tourette Syndrome had an increased risk for anxiety (OR = 1.4; 95% CI, 1-1.9), but a decreased risk for substance use disorders (OR = 0.6; 95% CI, 0.3-0.9), according to data.

      Genetic relationships were observed between Tourette Syndrome, OCD, ADHD, anxiety disorders, mood disorders and disruptive behavior disorders, the researchers added. – by Samantha Costa

      Disclosure: Scharf reports receiving research support, honoraria, and travel support from the Tourette Syndrome Association. Please see the full study for a list of all other authors’ relevant financial disclosures.
      TouretteLinks Forum


      • #4
        Mood, Anxiety Disorders Common in Tourette, at a Young Age

        Mood, Anxiety Disorders Common in Tourette Patients, Emerge at a Young Age

        Obsessive-Compulsive Disorder, ADHD Are Shown To Be Risk Factors For Additional Psychiatric Disorders In Largest Study To Date

        University of California San Francisco
        March 9, 2015

        A new study of Tourette syndrome (TS) led by researchers from UC San Francisco and Massachusetts General Hospital (MGH) has found that nearly 86 percent of patients who seek treatment for TS will be diagnosed with a second psychiatric disorder during their lifetimes, and that nearly 58 percent will receive two or more such diagnoses.

        It has long been known that TS, which emerges in childhood and is characterized by troublesome motor and vocal tics, is often accompanied by other disorders, especially attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). In many patients these “comorbid” conditions cause more distress and disability for patients than TS tics themselves.

        But the size and rigor of the new study, conducted by an international group of researchers known as the Tourette Syndrome Association International Consortium for Genetics (TSAICG) and published in the February 11, 2015 online edition of JAMA Psychiatry, provides the most comprehensive and reliable picture of TS comorbidities to date, said Carol A. Mathews, MD, professor of psychiatry at UCSF and co-senior author of the new report.

        “This is the biggest data set of its kind that I know of,” Mathews said. “We’ve interviewed thousands of people and collected a huge wealth of clinical data, which has given us the opportunity to say something meaningful about the clinical presentation of Tourette syndrome.”

        Co-senior author Jeremiah Scharf, MD, PhD, of the MGH Psychiatric and Neurodevelopmental Genetics Unit (PNGU), an assistant professor of neurology at Harvard Medical School and TSAICG co-chair, said that the new findings should prove useful to his fellow neurologists, who often treat TS patients but may not be aware of the full spectrum of possible psychiatric comorbidities seen in the disorder.

        “The origin of TS is in a part of the brain that is the overlap between neurology and psychiatry,” said Scharf. “Knowing the range of diagnostic possibilities and forming collaborative teams with psychiatrists is important to successfully treat TS.”

        Led by first authors Matthew E. Hirschtritt, MD, MPH, a psychiatry resident at UCSF, and Paul C. Lee, MD, MPH, a former postdoctoral fellow at the MGH PNGU, the researchers analyzed diagnostic data for more than 1,300 TS patients gathered in consistent, highly structured interviews completed over the 16-year period from 1992 to 2008. In addition, to determine how comorbid conditions that are frequently seen in TS patients might run in families, the analysis also included diagnostic information from parents, siblings, and other relatives unaffected by TS.

        As expected, the report found that ADHD and OCD are common among those with TS. Seventy-two percent of the TS patients studied received one of these two diagnoses, and nearly one-third were diagnosed with both ADHD and OCD. ADHD was seen to emerge as early as age 5 in TS patients, and OCD before 10 years of age.

        But the results also show that mood disorders, anxiety disorders, and disruptive behavior disorders are quite common in TS patients—about 30 percent of patients received one of these diagnoses—and that mood and anxiety disorders appear much earlier in life in TS patients than is typical in the general population.

        “Anxiety and depression, which in the general population often emerge in adolescence and adulthood, are more likely to emerge early in life with TS, sometimes as early as age 5,” said Scharf. “Social anxiety and ADHD often start in TS patients before tics even arise, which emphasizes the importance of screening young patients for these conditions.”

        Moreover, the researchers found that the risk of mood and anxiety disorders is related to OCD and ADHD diagnoses: both mood and anxiety disorders are significantly more common in TS patients with a concomitant diagnosis of OCD or of combined OCD and ADHD.

        These observations are presumably a consequence of intertwined genetic relationships between these conditions, said Mathews. “We found that, while OCD and ADHD directly shared genetic relationships with TS, the other psychiatric disorders, such as mood and anxiety disorders, appear to share genetic relationships with ADHD and/or OCD, but not directly with TS. Perhaps of more relevance for clinicians, parental history of ADHD—but not tics or OCD —is associated with a nearly two-fold increase in the risk of having more than one co-occurring psychiatric disorder.”

        The researchers found relatively low rates of other psychiatric conditions, including eating disorders, psychosis, and substance abuse, among TS patients.

        Mathews and Scharf cautioned that their results are potentially skewed because many TS patients never seek medical attention for the disorder. “This is a somewhat biased sample, because the patients we studied came to a clinic or through the Tourette Syndrome Association. People who come to a clinic for treatment tend to have more severe TS or they have other psychiatric symptoms,” said Mathews. “But this work still gives clinicians a good idea of what they should be on the lookout for.”

        The research was funded by the Tourette Syndrome Association (TSA), the National Institute of Neurological Disorders and Stroke, the National Institute of Mental Health, a TSA Research Fellowship to Lee, and a Doris Duke Clinical Research Fellowship to Hirschtritt.

        UCSF is the nation's leading university exclusively focused on health. Now celebrating the 150th anniversary of its founding as a medical college, UCSF is dedicated to transforming health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with world-renowned programs in the biological sciences, a preeminent biomedical research enterprise and top-tier hospitals, UCSF Medical Center and UCSF Benioff Children's Hospitals.
        TouretteLinks Forum


        • #5
          Re: Mood, Anxiety Disorders Common in Tourette, at a Young Age

          Tourette's, OCD, ADHD: Closer Together Than We Thought
          Dr. Marco Grados
          Johns Hopkins Newsletter
          Summer 2009

          Dr. Marco Grados

          A recent large study on the genetics of Tourette’s syndrome has added clout to what many experts suspect: that underlying biology—common genes, most likely—can tie together Tourette’s, obsessive compulsive disorder (OCD) and ADHD.

          That doesn’t mean all patients with Tourette’s also have OCD and ADHD, says pediatric psychiatrist Marco Grados, who leads Hopkins’ part of an international consortium. “But likely a third of children with Tourette’s belong to a subset with all three disorders.” And being aware of that, Grados says, makes therapy more precise. It also supports what’s known of the pathology.

          “We see child after child at our clinic primarily with the motor or vocal tics of Tourette’s. But after a workup, you often find anxiety-based obsessive thinking and inattention with hyperactivity. Or perhaps they come with OCD and you see the other two.” Children may be prescribed conflicting therapies. And parents are frustrated, says Grados. They’ve often shuttled kids from a hometown pediatrician who diagnoses one disorder, to a psychologist who says it’s another, to a neurologist who finds yet a third.

          It can be a confused family that comes to Hopkins.

          The new NIH-sponsored work looked at more than 950 patients, siblings and parents from 220 families with Tourette’s, as collected by the Tourette Syndrome Association International Consortium on Genetics. From his background in mathematics and genetic epidemiology, Grados saw the sense of using “latent class analysis” on the large population. That’s a statistical technique that cherry-picks groups of people from a mass of motley data. A result? Patients with all three disorders newly stood out.

          A second analysis—calculate the odds of having family members with the triple problems—confirmed that if you have all three disorders, it’s more than likely that relatives do too. Such “breeding true” cries out, a culprit gene!

          “Perhaps”—and it’s a big perhaps, Grados says—“we should think of this triple disorder as a single new one.”

          The study makes ideas about a common pathology more plausible. OCD, ADHD and Tourette’s, it’s believed, likely live in the large circuit that connects various parts of the brain’s basal ganglia with the cerebral cortex. If, because of an errant gene, the loop is overactive or otherwise out of control, it makes sense that all three disorders would surface.

          All three developmental disorders are marked by a lack of inhibition, whether it’s not being able to control OCD’s intrusive thoughts or Tourette’s motor tics. It’s also intriguing, Grados adds, that the three illnesses tend to fade after adolescence. “Sometimes one or another will just melt away,” he says. Is it coincidental that Mother Nature’s so-called maturity pathways—those descending from the reasoning cortex to lower regions like the basal ganglia—get stronger then?

          More immediate, though, is the clinical value of seeing the disorders as a set. “Because treatments for all three diverge,” says Grados, “prescribing becomes a careful balancing act.” Tourette’s for example, calls for medications that turn down dopamine. ADHD requires just the opposite with stimulants like Ritalin. “You can’t just say, the ADHD’s the worst. I’m going to treat that and let the others ride. That could aggravate the Tourette’s.

          “You put the pieces together,” he says, “and things start to make sense.”
          TouretteLinks Forum