Editing Tourette syndrome (section)

=== Co-occurring conditions ===
[[File:JFK, Marie-Madeleine Lioux, André Malraux, Jackie, L.B. Johnson, unveiling Mona Lisa at National Gallery of Art.png|thumb|left|alt=Three men and two women stand near the Mona Lisa. All are dressed formally, one woman in a spectacular pink gown.|[[André Malraux]] (center) was a French Minister of Culture, author and adventurer who may have had Tourette syndrome.<ref name=Kammer>{{cite book |veditors=Bogousslavsky J, Hennerici MG |title=Neurological Disorders in Famous Artists - Part 2 |vauthors=Kammer T |chapter=Mozart in the neurological department – who has the tic? |volume=22 |pages=184–192 |date=2007 |type=Historical biography |chapter-url= https://www.uni-ulm.de/~tkammer/pdf/Kammer_2007_Mozart_preprint.pdf |pmid=17495512 |doi=10.1159/000102880 |archive-url=https://web.archive.org/web/20120207145220/http://www.uni-ulm.de/~tkammer/pdf/Kammer_2007_Mozart_preprint.pdf |archive-date=February 7, 2012 |series=Frontiers of Neurology and Neuroscience |location=Basel |isbn=978-3-8055-8265-0 |publisher=Karger}}</ref><ref>{{cite book | vauthors = Todd O |title= Malraux: A Life |publisher= [[Alfred A. Knopf]] |year= 2005|isbn= 978-0375407024 |url= https://archive.org/details/malrauxlife0000todd/page/6/mode/2up?view=theater&q=Tourette%27s |page=7}}</ref><ref>{{cite journal |vauthors=Guidotti TL |title=André Malraux: a medical interpretation |journal=J R Soc Med |volume=78 |issue=5 |pages=401–406 |date=May 1985 |pmid=3886907 |pmc=1289723 |doi=10.1177/014107688507800511 |type= Historical biography}}</ref>]]

Because people with milder symptoms are unlikely to be referred to specialty clinics, studies of Tourette's have an inherent [[biased sample|bias]] towards more severe cases.<ref name=Bloch2011>{{cite journal |vauthors=Bloch M, State M, Pittenger C |title=Recent advances in Tourette syndrome |journal=Curr. Opin. Neurol. |volume=24 |issue=2 |pages=119–125 |date=April 2011 |pmid=21386676 |pmc=4065550 |doi=10.1097/WCO.0b013e328344648c |type= Review}}</ref><ref>See also
* {{cite journal |vauthors=Schapiro NA |title="Dude, you don't have Tourette's:" Tourette's syndrome, beyond the tics |journal=Pediatr Nurs |volume=28 |issue=3 |pages=243–246, 249–53 |date=2002 |pmid=12087644 |type= Review |url=http://www.medscape.com/viewarticle/442029|archive-url=https://web.archive.org/web/20081205082825/http://www.medscape.com/viewarticle/442029 |archive-date=December 5, 2008 |ref=none}}
* {{cite journal |vauthors=Coffey BJ, Park KS |title=Behavioral and emotional aspects of Tourette syndrome |journal=Neurol Clin |volume=15 |issue=2 |pages=277–89 |date=May 1997 |pmid=9115461 |doi=10.1016/s0733-8619(05)70312-1 |type= Review|ref=none}}</ref> When symptoms are severe enough to warrant referral to clinics, ADHD and OCD are often also found.<ref name=Stern2018 /> In specialty clinics, 30% of those with TS also have [[mood disorder|mood]] or [[anxiety disorder]]s or disruptive behaviors.<ref name= Dale2017 /><ref name=Hirsch2015>{{cite journal |vauthors=Hirschtritt ME, Lee PC, Pauls DL, et al |title=Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette syndrome |journal=JAMA Psychiatry |volume=72 |issue=4 |pages=325–333 |date=April 2015 |pmid=25671412 |pmc=4446055 |doi=10.1001/jamapsychiatry.2014.2650 }}</ref> In the absence of ADHD, tic disorders do not appear to be associated with disruptive behavior or functional impairment,<ref name=CommunitySample>{{cite journal |vauthors=Scahill L, Williams S, Schwab-Stone M, Applegate J, Leckman JF |title=Disruptive behavior problems in a community sample of children with tic disorders |journal=Adv Neurol |volume=99 |pages=184–190 |date=2006 |pmid=16536365 |type= Comparative study}}</ref> while impairment in school, family, or peer relations is greater in those who have more [[comorbid]] conditions.<ref name=Dure /><ref name= Morand /> When ADHD is present along with tics, the occurrence of [[conduct disorder]] and [[oppositional defiant disorder]] increases.<ref name= Dale2017 /> Aggressive behaviors and angry outbursts in people with TS are not well understood; they are not associated with severe tics, but are connected with the presence of ADHD.{{sfnp|Sukhodolsky|Gladstone|Kaushal|Piasecka|2017|p= 245}} ADHD may also contribute to higher rates of anxiety, and aggression and anger control problems are more likely when both OCD and ADHD co-occur with Tourette's.<ref name= Robertson2017 />

Compulsions that resemble tics are present in some individuals with OCD; "tic-related OCD" is hypothesized to be a subgroup of OCD, distinguished from non-tic related OCD by the type and nature of obsessions and compulsions.<ref name=Hounie>{{cite journal |vauthors=Hounie AG, do Rosario-Campos MC, Diniz JB, et al|title=Obsessive-compulsive disorder in Tourette syndrome |journal=Adv Neurol |volume=99 |pages=22–38 |date=2006 |pmid=16536350 |type= Review}}</ref> Compared to the more typical compulsions of OCD without tics that relate to contamination, tic-related OCD presents with more "counting, [[intrusive thought|aggressive thoughts]], symmetry and touching" compulsions.<ref name= Dale2017 /> Compulsions associated with OCD without tics are usually related to obsessions and anxiety, while those in tic-related OCD are more likely to be a response to a premonitory urge.<ref name= Dale2017 /><ref>{{cite journal |vauthors=Katz TC, Bui TH, Worhach J, Bogut G, Tomczak KK |title=Tourettic OCD: Current understanding and treatment challenges of a unique endophenotype |journal=Front Psychiatry |volume=13 |pages=929526 |date=2022 |pmid=35966462 |pmc=9363583 |doi=10.3389/fpsyt.2022.929526 |doi-access=free }}</ref> There are increased rates of anxiety and depression in those adults with TS who also have OCD.<ref name= Robertson2017 />

Among individuals with TS studied in clinics, between 2.9% and 20% had autism spectrum disorders,<ref>{{cite journal |vauthors=Cravedi E, Deniau E, Giannitelli M, et al |title=Tourette syndrome and other neurodevelopmental disorders: a comprehensive review |journal=Child Adolesc Psychiatry Ment Health |volume=11 |pages=59 |date=2017 |issue=1 |pmid=29225671 |pmc=5715991 |doi=10.1186/s13034-017-0196-x |type= Review |doi-access=free }}</ref> but one study indicates that a high association of [[autism]] and TS may be partly due to difficulties distinguishing between tics and tic-like behaviors or OCD symptoms seen in autistic people.<ref>{{cite journal |vauthors=Darrow SM, Grados M, Sandor P, et al |title=Autism spectrum symptoms in a Tourette's disorder sample |journal=J Am Acad Child Adolesc Psychiatry |volume=56 |issue=7 |pages=610–617.e1 |date=July 2017 |pmid=28647013 |pmc=5648014 |doi=10.1016/j.jaac.2017.05.002 |type= Comparative study}}</ref>

Not all people with Tourette's have ADHD or OCD or other comorbid conditions, and estimates of the rate of pure TS or TS-only vary from 15% to 57%;{{efn| According to Dale (2017), over time, 15% of people with tics have only TS (85% of people with Tourette's will develop a co-occurring condition).<ref name= Dale2017 /> In a 2017 literature review, Sukhodolsky, et al. stated that 37% of individuals in clinical samples had pure TS.{{sfnp|Sukhodolsky|Gladstone|Kaushal|Piasecka|2017|p= 244}} Denckla (2006) reported that a review of patient records revealed that about 40% of people with Tourette's have TS-only.<ref name=DencklaReview>{{cite journal |vauthors=Denckla MB |title=Attention-deficit hyperactivity disorder (ADHD) comorbidity: a case for "pure" Tourette syndrome? |journal=J. Child Neurol. |volume=21 |issue=8 |pages=701–703 |date=August 2006 |pmid=16970871 |doi=10.1177/08830738060210080701 |s2cid=44775472 |type= Review}}</ref><ref name=Denckla>{{cite journal |vauthors=Denckla MB |title=Attention deficit hyperactivity disorder: the childhood co-morbidity that most influences the disability burden in Tourette syndrome |journal=Adv Neurol |volume=99 |pages=17–21 |date=2006 |pmid=16536349 |type= Review}}</ref> Dure and DeWolfe (2006) reported that 57% of 656 individuals presenting with tic disorders had tics uncomplicated by other conditions.<ref name=Dure />}} in clinical populations, a high percentage of those under care do have ADHD.<ref name=Swain />{{sfnp|Sukhodolsky|Gladstone|Kaushal|Piasecka|2017|p= 244}} Children and adolescents with pure TS are not significantly different from their peers without TS on ratings of aggressive behaviors or conduct disorders, or on measures of social adaptation.<ref name= Hollis /><!-- p. 3--> Similarly, adults with pure TS do not appear to have the social difficulties present in those with TS plus ADHD.<ref name= Hollis /><!-- p. 3 -->

Among those with an older age of onset, more [[substance abuse]] and [[mood disorder]]s are found, and there may be [[self-injurious behavior|self-injurious]] tics. Adults who have severe, often treatment-resistant tics are more likely to also have mood disorders and OCD.<ref name= Robertson2017 /> Coprolalia is more likely in people with severe tics plus multiple comorbid conditions.<ref name= Ludolph2012 />