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Mind & Brain, the Journal of Psychiatry


conditions such as obsessive-compulsive and self-injurious behaviors determined overall staging of TS severity in the latter study was not specified. However, in follow-up studies by the same investigator,9,10 multivariate analyses showed that the presence or absence of tics was not correlated with drug or alcohol abuse in TS, whereas childhood discipline problems and obsessive-compulsive behaviors were signifi- cant associations. Strengthening the link between TS and substance use disorder (SUD), a family history study has shown a significant increase in the frequency of alcoholism and/or drug abuse among first-, second-, and third-degree relatives of TS probands.12 This suggests that the genes responsible for TS may play an important role in drug abuse and dependence.


Lending further credence to the possible inclusion of SUD in


the behavioral phenomenology of TS is the appreciation of common psychic urges or cravings as well as overlapping neurocognitive dysfunction in TS and addictive behaviors.1315 More fundamentally, it has been suggested that many of the comorbid psychopathological states that are commonly seen in TS, including mood and impulse-control dysregulation, are at the core of both the origins and clinical manifestations of addiction.16 However, the possibility that more severe forms of mood and impulse-control dysregulation might be risk factors for SUD in TS has not previously been examined. SUD may also have a complex relationship with tic control and expression in TS, with a potential to interact bidirectionally with the tic disorder. Thus, tics tend to be significantly aggravated by cocaine,17 but may be ameliorated by marijuana, benzodiazepines, or alcohol.1820 This suggests a need to examine critically the profile of substance abuse in TS.


Accordingly, the primary objectives of our study were to assess in a clinic population of adult TS patients (1) the frequency and profile of SUD and (2) the relationship of SUD to compulsive and impulsive behaviors as well as affective instability.


PATIENTS We included in this study adult TS patients, 20 years of age


and older, who had been followed for at least 1 year at a University-based TS clinic and who had received a semi- structured interview regarding comorbid conditions, includ- ing substance abuse (see below). All subjects had received standardized ratings for severity of tics, OCD, and ADHD, as well as assessment of mood disorders and global functional status. For patients followed longitudinally, the latest clinical ratings were used. Patients with mental retardation, pervasive development disorder, and active psychosis were excluded.


Our study population consisted of 66 adult TS patients,


followed for a mean period of 8.296.2 years. There were 45 males and 21 females, aged 38.3916.4 years (range 20.280.1 years). At last follow-up visit, the group’s mean Yale Global Tic Severity Scale (YGTSS) score was 38.4917.2 (range: 3.0 81.0), with a mean YaleBrown Obsessive-Compulsive Scale (Y-BOCS) score of 9.297.8 (range: 030); median Global Assessment of Functioning (GAF) scale score was 65 (range:


M&B 2011; 2:(1). July 2011 10


4590). Current medications included neuroleptics (n43, 65.2%), SSRIs (n33, 50.0%), and stimulants (n5, 7.6%).


METHODS


SUD was evaluated using retrospective review of all available clinical records and clinical interview, which included a modified version of The Centre for Addiction and Mental Health Concurrent Disorders Screener (CAMH-CDS).21 This covered the following Axis 1 conditions: major depressive disorder, dysthymic disorder, bipolar disorder (BD), agor- aphobia, panic disorder with and without agoraphobia, specific phobia, social phobia, OCD, generalized anxiety disorder, and abuse of or dependence on the following substances: barbiturates, benzodiazepines, cannabis, cocaine, heroin or opium, over-the-counter or prescription opiates, stimulants, and other drug or polydrug dependence. With this tool, sensitive screening questions are asked for each disorder. A ‘‘yes’’ answer to a screening question is followed by the minimum number of questions required to meet DSM- IV criteria.22 for that particular disorder. Considering the importance and prevalence of OCD in TS symptomatology, milder forms of obsessive-compulsive behavior insufficient to meet DSM-IV criteria for OCD, including obsessional worry- ing, were also recorded. DSM-IV criteria were used for diagnosis of TS and all comorbid disorders, currently active and in remission, except for adult ADHD, where proposed DSM-V criteria were employed.23 Rage, which was defined as the presence of intermittent episodes of sudden, uncontrol- lable explosive or aggressive behaviors grossly out of proportion to provocation and atypical for the individual’s normal personality, was assessed in all subjects using a modification of DSM-IV criteria for intermittent explosive disorder (IED), omitting criterion C (i.e., that aggressive episodes are not better accounted for by another mental disorder, medication or drug, or general medical condition) (cf. Budman et al.24).


Tic severity in study subjects was assessed by the YGTSS.25


This rates severity of motor and vocal tics across five different domains (number, frequency, intensity, complexity, and interference), each rated from 0 to 5. The sum of domain scores provides total motor and vocal tic scores, which are combined with a 050 overall impairment rating to yield the global severity score (range 0100). Severity of obsessive-compulsive symptoms (OCB) was assessed by the Y-BOCS.26 Seven-point anchored Clinical Global Impression (CGI) scales were used to assess overall severity of residual ADHD symptoms and previous childhood ADHD.27 Func- tional status was assessed by the GAF Scale.22


TS patients with and without histories of SUD (SUD and


SUD, respectively) were compared by demographic vari- ables as well as by (a) most recent ratings for tics (YGTSS) and OCD (Y-BOCS); (b) CGI ratings for adult and childhood ADHD; and (c) prevalence of self-injurious behaviors (SIB), rage attacks, BD, depressive disorder, and anxiety/panic disorder.


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