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Substance use disorder in adult Tourette syndrome


Fisher’s Exact test and Chi-square tests were used for comparison of categorical and ordinal variables, and Stu- dents’ t-test for two independent groups for comparison of continuous variables. Factors predictive of SUD in the univariate analyses were then entered into a logistic regres- sion analysis to examine the relative importance of each factor. JMP 7 software (SAS Institute Inc., Cary, NC, USA, 2007) was used for the statistical analyses.


RESULTS A total of 15 of the 66 patients (22.7%) had a history of


SUD, including substance abuse (n9), polysubstance abuse (n2), substance dependence (n2), and polysubstance dependence (n2). Drugs alone or in combination included alcohol (n7, the sole abused substance in two cases), cannabis (6), benzodiazepines (5), opioids (4), and cocaine (4). Physician recognition of cocaine abuse was delayed in one of the latter individuals despite the subject’s awareness of its adverse impact on her tic disorder. One patient each had a history of SUD involving barbiturates, methamphetamine, anabolic steroids, and carisoprodol. In seven patients, cannabis, benzodiazepines, or alcohol were used at least partially to calm tics or ameliorate psychic tension or anxiety. Drug abuse caused or contributed significantly to employ- ment difficulties in five cases. Other complications of SUD included functionally significant apathy (n1), divorce (n 1), homelessness (n1), incarceration (n5), and loss of child custody (n3). Two patients died unexpectedly of drug overdoses.


TS subjects with SUD did not differ from their drug-free counterparts with respect to age (33.7910.8 years vs 37.59 14.2 years, respectively, p0.86) or gender (73% vs 67% male, respectively, n0.76). GAF scale score was signifi- cantly lower in the SUD group compared with subjects without such history (59.097.6 vs 67.599.6, p0.0036). However, severity of tics and OCD was similar for the two groups, as was severity of adult and childhood ADHD (see Table 1). There was a nonsignificant trend toward greater frequency of childhood ADHD in patients with SUD (8/15, 53.3%) compared with those without SUD (15/51, 29.4%) (Chi-square2.82, p0.09), and no difference in frequency of residual adult ADHD (5/15, 33.3% vs 10/51, 19.6%, p 0.30). Severe SIB (forceful eye poking, punching of glass, and violent banging of the hand against other hard objects, resulting in repetitive hand injury and corrective surgery; forceful head banging and biting of the buccal mucosa, resulting in bleeding) was limited to three patients. Two of these subjects had a history of SUD, consisting of cocaine dependence and polysubstance abuse, accompanied by severe tics. Overall, however, SIB of any severity was not signifi- cantly different between the two groups (Table 2).


When affective disorders were examined, there was no difference in frequency of depressive disorder (major depres- sion or dysthymia) for subjects with and without SUD. Similarly, for anxiety disorders, the study groups did not differ with respect to frequency of individuals with OCD, obsessional worrying/anxiety disorder NOS, generalized


www.slm-psychiatry.com 11


Table 1. Comparison of Clinical Ratings in Subjects With and Without a History of Substance Use Disorder


Rating


Y-BOCS Motor tic score Vocal tic score Total tic score Total score


Y-BOCS


Obsessions Compulsions Total score


Adult ADHD (CGI) None


Borderline Mild


Moderate Marked/severe


Childhood None


ADHD (CGI)


Borderline Mild


Moderate Marked/severe


4 (26.7%) 3 (20.0%)


6 (40.0%) 2 (13.3%) 0


24 (47.1%) 12 (23.5%)


11 (21.6%) 3 (5.9%) 1 (1.9%)


0.411


SUD, substance use disorder; YGTSS, Yale Global Tic Severity Scale; Y-BOCS, Yale-Brown Obsessive-Compulsive Scale; CGI, Clinical Global Impression scale. YGTSS and Y-BOCS scores are means and standard deviations. Adult and childhood ADHD figures represent patient numbers and percentages for each CGI category.


anxiety disorder, or social phobia (Table 2). However, compared with other subjects, those with SUD were more likely to exhibit panic disorder (5/15, 33.3% vs 3/51, 4.9%, p0.01).


In four patients, emotional lability was exhibited as rage


reactions, sometimes with assault or property destruction temporally unrelated to substance use, meeting DSM-IV diagnostic criteria A and B for IED. Such rage attacks were limited to theSUDgroup (p0.0019, see Table 2). In addition, BD was exhibited by twice as many patients (20.0%) with SUD as those without SUD (9.8%) although this difference was not statistically significant (p0.37). Rage attacks or BD was manifest by 6 of the 15 subjects (40%) with SUD compared with 5 of the 51 patients (9.8%) without SUD (p0.01, two- tailed Fisher’s Exact test). Although the association of affective lability with SUD was driven primarily by rage attacks, a history of either BD or rage attacks was considered as a single variable in the logistic regression analysis, to ensure stability of parameter estimates. In this analysis, SUD was strongly associated with both rage/BD (likelihood ratio Chi-square 8.248, p0.0041), and with panic disorder (likelihood ratio Chi-square8.518, p0.0035).


DISCUSSION Although the true prevalence of SUD in the general TS


population is not known, this study shows SUD to be common in a clinic sample of adult TS patients, supporting previous data.9 Using face-to-face interviews in a large rep- resentative sample of US adults, the National Epidemiologic Survey on Alcohol and Related Conditions found the


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


3.6 (4.4) 3.7 (3.4) 7.3 (6.2)


6 (40.0%) 4 (26.7%) 3 (20.0%) 2 (13.3%) 0


4.4 (4.8) 5.5 (4.1) 9.8 (8.2)


35 (68.6%) 6 (11.8%) 4 (7.8%) 5 (9.8%) 1 (2.0%)


0.74 0.95 0.89


SUD


11.1 (3.6) 7.9 (4.5) 18.9 (6.4) 42.9 (18.5)


SUD


10.8 (3.4) 6.2 (4.4) 17.0 (6.9) 37.0 (15.7)


p


0.39 0.12 0.16 0.14


0.266


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