Talk:Tourette syndrome

Recent reviews by Robertson, by Bloch, etc.

Here are some recent reviews on TS that look like they're worth reading and perhaps citing in Tourette syndrome. I haven't had a chance to look at them yet myself.

• Bloch MH (2008). "Emerging treatments for Tourette's disorder". Curr Psychiatry Rep. 10 (4): 323–30. PMID 18627671.
• Steeves TD, Fox SH (2008). "Neurobiological basis of serotonin-dopamine antagonists in the treatment of Gilles de la Tourette syndrome". Prog Brain Res. 172: 495–513. doi:10.1016/S0079-6123(08)00924-2. PMID 18772048.
• Robertson MM (2008). "The prevalence and epidemiology of Gilles de la Tourette syndrome. Part 1: the epidemiological and prevalence studies". J Psychosom Res. 65 (5): 461–72. doi:10.1016/j.jpsychores.2008.03.006. PMID 18940377.
• Robertson MM (2008). "The prevalence and epidemiology of Gilles de la Tourette syndrome. Part 2: tentative explanations for differing prevalence figures in GTS, including the possible effects of psychopathology, aetiology, cultural differences, and differing phenotypes". J Psychosom Res. 65 (5): 473–86. doi:10.1016/j.jpsychores.2008.03.007. PMID 18940378.
• Conelea CA, Woods DW (2008). "The influence of contextual factors on tic expression in Tourette's syndrome: a review". J Psychosom Res. 65 (5): 487–96. doi:10.1016/j.jpsychores.2008.04.010. PMID 18940379.
• Kremer HP (2007). "What's wrong with Tourette syndrome?". Parkinsonism Relat Disord. 13 (Suppl 3): S385–6. doi:10.1016/S1353-8020(08)70034-8. PMID 18267268.

Eubulides (talk) 08:06, 25 March 2009 (UTC)

Most of them look very promising; I will work on getting full text on all of them—except Steeves and Kremer, which I suspect will be of less value (in case you want to focus on those two? I prefer to focus on the better known researchers, and think those two topics might not add much to the article.) Thanks! SandyGeorgia (Talk) 13:43, 25 March 2009 (UTC)

Bloch

I still haven't gotten hold of this one. SandyGeorgia (Talk) 03:55, 7 April 2009 (UTC)

Kremer

Only a two-page paper, nothing new at all, just summarizing all of the reasons why it has been so hard to find the gene(s) and problems in defining the phenotype. I can't see anything worth adding from this article, but if anyone is curious, I can post some excerpts. SandyGeorgia (Talk) 03:55, 7 April 2009 (UTC)

Steeves

A long, very technical paper, addressing mostly brain circuitry, imaging studies, etc.—hard for me to get through, because I don't speak brain structures, and I'm not sure if it has anything new of use. I'll post the conclusions: let me know if more detail is wanted.

(DA = Dopamine) SandyGeorgia (Talk) 03:55, 7 April 2009 (UTC)

Evidence derived from both pharmacological trials and selected functional imaging studies suggests that disturbances of the dopaminergic and serotonergic neurotransmitter systems play an essential role in the pathogenesis of TS. Currently, key replicated findings from functional imaging studies have suggested that TS is characterized by increased release of DA in striatum in response to a stimulant challenge, widespread up-regulation of 5-HT2A receptors and decreased binding of the serotonin transporter. The original tonic-phasic model of DA release posited that elevated phasic release of DA in TS was due to understimulation of D2 autoreceptors, which was in turn secondary to low levels of tonic DA release; however, integrating the interactions between the dopaminergic and serotonergic systems into the tonic-phasic model may more adequately account for the current functional imaging findings as well as the phenomenology and pharmacology of TS. Stimulation of up-regulated 5-HT2A receptors may contribute to the elevated phasic release of DA in TS, and the up-regulation of 5-HT2A receptors may in turn be either a primary abnormality or a secondary one, due to the low tonic release of DA, as originally proposed in the tonic-phasic model. These observations suggest new avenues for investigation and treatment of this challenging disorder.

Prevalence is mentioned:

TS is not rare, and prevalence rates of up to 1–2% in schoolchildren and 0.5% in adults have been reported, although the severe cases that come to the attention of neurologists and psychiatrists are likely considerably less common than this (Hornse et al., 2001; Stern et al., 2005). Although the mode of inheritance for TS is unknown, a concordance rate of 86% in monozygotic twins compared to 20% in dizygotic twins points to the primacy of genetics in the development of the disorder (Price et al., 1985; Hyde et al., 1992).

Conelea

Scope and definitions

... there is increasing evidence that tic expression may not be the sole product of internal processes but is also influenced by contextual factors [18,19] that impact these biological processes. ... In this article, we review what is currently known about the effects of contextual variables on tic expression. By “contextual factors,” we refer to environmental events (e.g., presence or absence of specific stimuli, emotional reactions to life events, different settings or activities) that occur in a person's life that can have an immediate and direct impact on tic occurrence. This review does not include static historical variables more closely linked to biological etiologies, such as streptococcal infections [20], events occurring pre- or perinatally [21–24], or the impact of drugs upon tic expression.

We have organized our coverage into two general categories: antecedent and consequent factors. Antecedents are those events that occur prior to a tic, which, when present, alter the likelihood that the behavior will occur. In contrast, consequence factors are events that occur after a tic and serve to reinforce (increase) or punish (decrease) the behavior.

Antecedent factors

• Studies are limited because most are self- or parent-reports and aggregated, may not reflect individual response patterns. Also most studies don't describe medication history or how diagnoses were made. Also, none looked at impact on premonitory urge.
  • Show that fatigue and social activities exacerbate tics while relaxation, concentration and passive states attenuate tics.
• Long discussion of single-case experimental designs.

Combined, the experimental studies demonstrate that specific antecedent factors can influence tics. These include the presence of others [32,33], academic tasks [34], ticrelated conversation [35], verbal instructions to suppress tics [18], and overt observation [33]. ... these studies also have a number of limitations.

• Discussion of emotions and tics

Combined, these studies suggest that stress, anxiety, frustration, and tension are often associated with an increase in tics. Nevertheless, a number of methodological concerns limit our ability to make specific conclusions about the role of emotional variables on tics.

Consequence factors

• All had methodological limitations, future research should address whether findings are generalizable.

Summary

Research examining the impact of contextual factors on tic expression has increasingly generated support for the hypothesis that variability in tic expression may, in part, be explained by contextual factors. Overall, findings in this area indicate that several contextual factors are more commonly associated with tic exacerbations. Stressful, frustrating, or anxiety-provoking events were reported to exacerbate tics in several studies [25,26,28,29,38–40,42], but this finding has not been universal [30]. Although these types of events are frequently reported to exacerbate tics, it is important to interpret this finding with caution.

Other contextual events frequently associated with tic exacerbation were fatigue [25–28], social events [25,28,30,33], and starting school in the fall [25]. Events frequently reported to coincide with tic reductions included social interactions with familiar people [28,29], situations in which the individual is a passive participant [29,30], and leisure activities [28,30]. Once again, it would be beneficial for future research to examine each reported event more closely to identify the specific contingencies involved in tic exacerbation or reduction.

• The general flavor of this paper is that we don't know as much about tic exacerbation and attenuation as we think we do; all studies are limited. Let me know if further detail is wanted. We may need to add a sentence or two on this somewhere. SandyGeorgia (Talk) 03:55, 7 April 2009 (UTC)

• hmmm, looks like this isn't specifically addressed in this article, so there may be no need to change anything. The tic article says: Tics may increase as a result of stress, tiredness, or high energy emotions, which can include negative emotions, such as anxiety, but positive emotions as well, such as excitement or anticipation. Relaxation may result in a tic increase (for instance, watching television or using a computer), while concentration in an absorbing activity often leads to a decrease in tics. SandyGeorgia (Talk) 04:06, 7 April 2009 (UTC)

Robertson Part 1

• Suggests 1% "overall international GTS prevalence" figure (in line with Kremer).
• Long discussion of methodological problems affecting studies: (I believe we've summarized this adequately for an overview article with "Discrepancies across current and prior prevalence estimates come from several factors: ascertainment bias in earlier samples drawn from clinically referred cases, assessment methods that may fail to detect milder cases, and differences in diagnostic criteria and thresholds.")
• The African question is examined more closely in part 2.

These reports and studies highlight the fact that GTS is found in all social classes and in most cultures and racial groups apart from sub-Sahara black African (where it is rare) and the African-American black population in which groups GTS was uncommonly reported. It also suggests that GTS may be more common in South African Afrikaners (Afrikaans speaking of primarily Dutch origin). All studies agree that GTS occurs more in males than in females, with a figure of approximately 4:1.

• Discusses methodological problems in various earlier studies cited (we've covered all of this before).
• Prevalence in ASD and SPED

In people with ASDs, GTS is more common. In two studies from the author's group and collaborators in the UK, embracing a total of 484 people with ASD [69,70], the prevalence of GTS was much higher (6.0%). A recent investigation by Canitano and Vivanti [71], undertaken in Italy, included 105 children and adolescents with ASDs: GTS was reported to occur in as many as 11%. Furthermore, individuals in special educational settings for people with learning difficulties such as mental retardation and those with emotional and behavioral difficulties [47,55,72] have an even higher prevalence of GTS.

• Discusses prevalence of non-GTS tic disorders (can be added to that article).
• A strength of this paper is indepth analysis of all prior studies, but we've pretty well covered that in prior discussions. Conclusions:

In summary, GTS occurs in most races and is not rare: indeed, GTS is common. The prevalence of GTS (multiple motor and one or more phonic tics for more than a year's duration with a definite diagnosis) in young people in the community has been reported to be between 0.4% and 3.8% internationally. A figure of 1% overall has been calculated by the author as a representative accurate overall figure: the studies used for the calculation were conducted on youngsters aged 5–18 years. There is a possibility that GTS may be more common in Western Caucasians than in Oriental populations. In sub-Saharan black Africans, however, GTS is extremely rare (Xhosa 0.046% prevalence). In the American Black population, GTS is only represented between 0.5–8.7% of cases who have been identified in clinical cohorts. In people with learning difficulties requiring special educational placement, it is common, and in those individuals with ASDs, GTS prevalence is as high as 6–11%. In adult psychiatric settings, GTS is not common, however. In other words, although GTS is associated with psychopathology (ADHD, OCB/D, depression) it is not associated with major psychiatric disorder (e.g., schizophrenia, bipolar affective disorder) which necessitates admission. It appears that motor tics are very common indeed, with a point prevalence of between 7% and 28%, but this depends on age, gender, and season. Tics are also more common in young people with learning or behavioral difficulties and ASDs.

• Specific numbers we may want to include:

As the GTS symptoms decrease with age, but the individual still has GTS and indeed the majority (90%) of adults at follow-up probably have tics (e.g., the gene[s]), the present author suggests that the overall prevalence rate in the whole population is more than 1% (i.e., in all settings, such as “healthy” individuals as well as those who have or had other disorders and educational and behavioral difficulties). Thus, to give a figure, in the UK, for example, in the 2001 census, there was a total of 55 302 941 individuals (from the ages 5 to above 90 years), and thus, approximately 553 thousand individuals in the UK over the age of 5 years would have GTS, albeit mild and almost unrecognizable by the time they were older (http://www.statistics.gov.uk/census2001/ pyramids/pages/UK.asp).

SandyGeorgia (Talk) 20:12, 7 April 2009 (UTC)

Thanks for looking into it. Robertson part 1 appears to be a very strong source on epidemiology, and part 2 will probably be as well. I just now reread Tourette syndrome #Epidemiology in light of the above, and have some comments and suggestions:

• Currently Epidemiology doesn't talk about comorbid conditions, but Robertson does. This topic is a big deal, and should be added to the article.

• Shall I excerpt some of that or can you write it? SandyGeorgia (Talk) 21:29, 7 April 2009 (UTC)

• I can't write it right now, I'm afraid. I could look into it in a day or two. I'm sure you'd do a great job excerpting.... Eubulides (talk) 21:43, 7 April 2009 (UTC)

• Likewise for the regional and racial variations.

• Excerpted here, looks easily doable. SandyGeorgia (Talk) 21:29, 7 April 2009 (UTC)

• I agree that a brief summary of prevalence of non-TS tic disorders would be helpful, to place the epidemiology into context.

• I'll excerpt then. SandyGeorgia (Talk) 21:29, 7 April 2009 (UTC)

• Oops, see I already have that in conclusions above. SandyGeorgia (Talk) 21:36, 7 April 2009 (UTC)

• Currently Epidemiology paragraph 1 talks about various groups (social, racial, age). Paragraph 2 talks at length about how hard it is to do epidemiology. Paragraph 3 talks about historical estimates and then (finally!) current estimates of prevalence. A naive reader would, I think, prefer a different order: overall prevalence, prevalence in groups, and then difficulties (including historical estimates). That is, a naive reader would prefer first seeing a quick global picture (overall prevalence); then more detail about groups (races, ages, etc.), and then finally the footnote-like stuff about how hard it is to get these numbers (most readers won't care about this, but we should include it anyway since it's important).

• Sounds good. (We had trouble with this several years ago, but now we have a more authoritative review.) SandyGeorgia (Talk) 21:29, 7 April 2009 (UTC)

• The article's current "1–10 children per 1,000 have Tourette's" comes from Lombroso & Scahill 2008 (PMID 17937978), and I tend to think we should stick with this wider-range estimate instead of Robertson's simpler "1%", as it's more conservative and reflects a wider range of opinion.

• Sounds good. SandyGeorgia (Talk) 21:29, 7 April 2009 (UTC)

• Is that arithmetic about the UK ours, or Robertson's? I continue to be leery of absolute numbers. Percentages provide better global perspective: a reader in (say) Sydney (pop. 4 million) can easily figure that with a prevalence of 1% then about 400,000 people in Sydney have TS, whereas the 500,000 UK figure isn't that useful worldwide. If we can find a reliable source that says something like "in 2008 an estimated 60 million people worldwide had TS" that would be OK, I guess; otherwise I would limit the discussion to percentages or ratios if that's what Robertson does. (I realize we have discussed this before but wanted to raise it again, since it still bugs me. :-)

• That arithmetic is hers (all of the block quotes I excerpted are direct quotes). SandyGeorgia (Talk) 21:29, 7 April 2009 (UTC)

• Ah, thanks, that overcomes my objections. Eubulides (talk) 21:43, 7 April 2009 (UTC)

Eubulides (talk) 21:17, 7 April 2009 (UTC)

Robertson Part 2

• Lots of info here, the most interesting of these papers so far, but either we've already included the info or information may be too detailed/specific for an overview article.
• Another very long discussion of the methodological issues in prevalance studies—territory we've covered and I think summarized well enough for a review using the Scahill material, but if we want to expand there is plenty of material here.
• Says that lower prevalance rates in Oriental populations may be real. (Japan, Hong Kong, Taiwan, China, although Chinese include impairment. Notes that "Asians have an often lower or equal risk of Tardive dyskinesia (TD) than Caucasians [27].") Then ...

With regard to the South African data, the sub-Saharan Africa data and possibly the African American data [3], matters are much more complex than meets the eye. The following reasons are all possible and will be discussed briefly: (i) other medical priorities and less propensity to seek health care, (ii) lack of awareness of GTS, (iii) chance, (iv) ethnic and epigenetic differences and reasons, (v) genetic and allelic differences in different races, and (vi) an admixture of races.

Fourthly, it appears that there are indeed ethnic differences in both movement disorders and other disorders, and this may explain the differing GTS prevalence results. For example, several early studies suggested that African Americans had lower rates of Parkinson's disease than Caucasians, whereas later studies failed to show such a difference. Studies have also shown that African-American people have a higher risk of TD than Caucasians, but Asians have a lower or equal risk of TD when compared to Caucasians [27]. Another possibility in the African American population is that great selection pressures operated in terms of choice of slaves (possibly excluding the ones who had developmental problems), and so, those who actually physically survived the crossing may have had increased problems (e.g., those able to retain salts and resist dehydration is an explanation for the increase of hypertension in African Americans [33]).

• Long discussion of adaptations to survival, which may reflect true genetic differences.
• Relative to discussion in the next section: "The actual cause of the brain dysfunction underlying GTS is as yet unknown, but it is certain that the syndrome is familial with a genetic component in the majority of cases."
• Future directions: "Few attempts have been made to formally classify GTS patients on the basis of their tic phenomenology, and one must also consider the effects of psychopathology when considering phenotype and therefore prevalence and epidemiology. In addition to the complex aetiology of GTS with genetic heterogeneity, it appears that GTS is not a unitary condition, and there is clinical heterogeneity as well. ... In addition, much more evidence for GTS not being a unitary condition comes from recent studies ... " (This reflects the work being done to identify more homogeneous subsets of TS subjects ... an area of interest, but unsure if needed yet in an overview article?) "All these studies add to the growing body of evidence that GTS is not a unitary condition and can be disaggregated into more homogeneous symptom components. ... Thus, the phenotype of GTS is much more complicated than was previously thought, and there is almost certainly aetiological as well as clinical and phenotypic heterogeneity. These differing phenotypes would certainly affect the GTS prevalence."
• "One suggestion may be that to have GTS or some of its phenotypes (e.g., OCB) may well be positively advantageous to the species." (Possible addition to topic explored in Kathryn Taubert chapter in the Leckman/Cohen book.)
• Conclusion: "It is suggested that, for GTS, there should be a nomenclature change, along the lines of both phenotypes and aetiologies." and ... "The only factor which has been replicated, several times in fact, is that of a “pure simple motor and phonic tic factor,” and which all specialist clinicians treating patients with GTS are able to identify clinically. Thus, it is suggested that TS will be patients with simple motor and phonic/vocal tics only. Other subtypes may follow, and it is likely that these will mirror the clusters and factors defined by the studies (see Table 2), for example, TS+OCD, or TS+ADHD."
• Remember Hirtz? Robertson didn't seem to care for it :) "What is extraordinary is that a recent study in the United States published in 2007, which estimated the incidence and prevalence of 12 neurological disorders which were supposed to be “common,” the authors reported that, “for Tourette Syndrome, the data were insufficient” [113].
• Final conclusion: "It is further suggested that the prevalence of one type of GTS (or TS, with “pure” or simple motor and phonic tics only as the symptomatology) is at least 1% of youngsters in the community, in the majority of the world apart from sub-Saharan black Africa and the African-American people, where GTS appears uncommon or rare."

SandyGeorgia (Talk) 21:21, 7 April 2009 (UTC)

Thanks again. Some further comments.

• I agree we shouldn't expand on epidemiology methodology, but we should still cite this paper (as it appears to be our best source on the subject), perhaps modifying the discussion to match the source better.
• The points that it appears that TS is not a unitary condtion, and that it's almost certain that it is heterogeneous not only in cause but also in phenotype and clinically, and that subtypes may follow, are very important topics, and should be covered in Tourette syndrome somewhere. We're seeing this also in autism; see, for example, the last paragraph of Autism #Classification, which cites Stephan 2008 (PMID 18179879).

• She hedges a bit at the end of the paper, saying this isn't as far along with TS as it is with ASD: should I excerpt? (Worried that I'm borderline passing Fair Use if I excerpt too much.) These two papers are worth getting, while the others are less helpful. SandyGeorgia (Talk) 21:38, 7 April 2009 (UTC)

• Thanks, I'll get copies in a day or so; no need to excerpt for me. Eubulides (talk) 21:44, 7 April 2009 (UTC)

• The "positively advantageous to the species" business is a common speculation in autism, too, and has been for years. I'd treat this gingerly, and would not emphasize it or imply that it's a given, as there's no scientific evidence for this speculation and there's more than a whiff of politics involved. For what it's worth, Autism ignores this minefield entirely, as I found no reliable sources on it.

Eubulides (talk) 21:33, 7 April 2009 (UTC)

"Biological"

DSM-IV:

In the DSM it says that ALL of the conditions are unexplained by medical science. So, the initial description of the condtion as being biological and running in families is incorrect.

Tourette's could be biological, it could be some strange passive-aggressive expression, it could be some kind of psychosis, or something else entirely. Whatever the case, if there was proof of a bio basis, it would then be taken out of the DSM and placed in a medical category, and not a mental one.

There's a variety of medical problems which cause mental disturbance but they aren't in the DSM because we know the exact origin of the problem. Thus, it's known that a force outside of the mind (thought process) causes these things to happen, and that's why there's no DSM listing. The DSM is for unexplained problems which seem to stem from the mind.—Preceding unsigned comment added by 198.184.150.254 (talk • contribs) 12:49, 1 April 2009

Perhaps you are not familiar with twin studies; if you have reliable sources for any statements you would like to change or include, pls list them. SandyGeorgia (Talk) 13:18, 1 April 2009 (UTC)

Twin studies get called into question themselves. There's a variety of reasons why they may not be valid and those include the removal of data which doesn't support the hypothesis and the fact that many twins in said studies grow up in very similar situations. Frankly, from reading many, it appears that the sample size (meaning removal of data) is so small as to be meaningless. It's an example of searching for data that supports your hypothesis rather than being objective.

Whatever, the case. it stands that the DSM states that no condition in the book has an explanation. That's fact and it's a major aspect of the treatment of mental health conditions. One, or fifty, studies on a DSM topic don't change that.

This idea is different from "real" medical conditions which have defined treatments based on biochemistry. The treatment of diabetes, for instance, isn't open to interpretation it's chemical and diet based. Mental problems tend to be approached in a variety of ways or combos of them. Some use talk and medication therapy or either. It is in fact true that ALL mental health meds carry the explanation "we don't know why this works" as the mechanism of action.

So, the cause of this "mental problem" should be removed from the article. —Preceding unsigned comment added by 198.184.150.254 (talk) 14:46, 1 April 2009 (UTC)

I'm not quite sure what you're arguing with. The article already says that there may be non-biological factors, and that there is no single biological explanation. The first sentence of the Causes section reads "The exact cause of Tourette's is unknown, but it is well established that both genetic and environmental factors are involved." rʨanaɢ ^talk/_contribs 14:58, 1 April 2009 (UTC)

My point is that it's not "well established" at all. The Desk Reference of the DSM-IV-TR, page 73, says: "D. The disturbance is not due to the direct physiological effects of a substance or a general medical condition." It says that because almost nothing in the DSM is given an explanation. All mental health studies suffer from "causation" problems and aren't the same as those done in the physical sciences. Researchers can't induce mental problems in people nor could they ethically allow others to, so they can only study after the fact, thus the idea of "inherited" is only a suggestion.

Problem: "is an inherited neuropsychiatric disorder." That's stated in the beginning of the article and it's incorrect on many levels. Firstly, it's wrong because such a conclusion cannot be made given the way studies are conducted. Secondly, the word "is" makes it a concrete fact. For instance we know what diabetes "is" caused by in pretty great detail, not so with any mental problem. Lastly, if a read takes the article as fact, then they might discount things like the effect a high pressure childhood might play in the development of a Tic Disorder, which is what Tourette's is classified as. In other words, the article invalidly closes the door on environmental factors because of the words "is an" in the beginning.

If you change those words to "could be" then you had better list other things it could be by researching theories regarding the development of Tic Disorders. My opinion is that it should be stated as having an unknown cause, and leave it at that. —Preceding unsigned comment added by 198.184.150.254 (talk) 15:13, 1 April 2009 (UTC)

Wikipedia articles are based on reliable sources (see WP:MEDRS, WP:RS and WP:V); if you have a reliable source backing your opinions, pls post it, and we can try to incorporate your views. SandyGeorgia (Talk) 15:20, 1 April 2009 (UTC)

I posted a quote from the DSM-TR about how to diagnose the condition, what more could be wanted?

The DSM isn't online because the book is copyrighten and must be purchased. So, someone will have to get the book and look it up to verify. Clearly, that wasn't done with this article because this article is what you're accusing me of, opinion. —Preceding unsigned comment added by 198.184.150.254 (talk) 15:30, 1 April 2009 (UTC)

DSM Criteria: http://www.psychtreatment.com/mental_health_tourettes.htm . No mention of "is inherited" in that.

Theory Not Fact: http://emedicine.medscape.com/article/289457-overview "The precise pathophysiologic mechanisms of TS are yet to be determined."

This link, after saying they have no idea what causes it, goes on to present a bunch of seemingly factual ideas about what does. http://ghr.nlm.nih.gov/condition=tourettesyndrome Link states theory but suggests it's a fact. —Preceding unsigned comment added by 198.184.150.254 (talk) 15:44, 1 April 2009 (UTC)

Alternate Ideas:

Studies find that Tourette's is link to Passive-Aggressive Personality Disorder: http://www.tourettesyndrome.net/tourette_primer3.htm Is there any indication that children or adults with TS are more likely to have personality disorders or other problems? Unfortunately, there has been very little "hard" research on this topic, although adults with TS who are seen in clinics generally present because of problems in anger management. In one of the few studies that looked at the question of personality disorders, Robertson et al. (1997) compared adult clinic patients with TS to undergraduate students and hospital staff. They reported that the TS patients were significantly more likely to have a personality disorder, and that many of the patients had more than one personality disorder. Their data indicate that about half of the adult TS patients had Borderline Personality Disorder and were also significantly more likely to have other personality disorders: Avoidant, Depressive, Obsessive-Compulsive, Paranoid, and Passive-Aggressive. However, one cannot tell from their study whether the personality disorder was causally linked to the Tourette's or rather to a comorbid condition -- or whether it was the result of having been misunderstood during their childhood and adolescence.

Passive-Aggressive Personality Disorder: http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=8165&cn=8 It's under study, but a feature of the this problem, and passive-aggressiveness in general, is the use of subtle and disguised attacks as a form of acting out. Noises, gestures, and so forth may be used by the person and likely the origin of this is due to the person believing themself oppressed in some way. So, behaviorally they get conditioned to not express themselves in a straight forward manner. —Preceding unsigned comment added by 198.184.150.254 (talk) 15:59, 1 April 2009 (UTC)

Please see #TS is inherited below. Eubulides (talk) 20:00, 1 April 2009 (UTC)

TS is inherited

• I'm afraid the above comments reflect a serious misunderstanding of the role of the DSM. The DSM is about diagnosis, not about causation, and the diagnostic criteria for Tourette's are deliberately written to be independent of causation. We cannot infer anything about causation from the DSM criteria; we can't even infer that the causes of TS are unknown.
• The idea that TS is not a "real" medical condition, or that it is not well-established that genetic and environmental factors play a role, is completely incorrect. Many sources are cited in Tourette syndrome to establish these claims.
• The lead sentence's claim that TS "is an inherited neuropsychiatric disorder" agrees with what reliable sources say. For example:

• "Tourette syndrome (TS) is an inherited developmental neuropsychiatric disorder characterized by vocal and motor tics." —Stillman et al. 2008, PMID 19105198
• "Gilles de la Tourette's syndrome (Tourette's syndrome; TS) is an inherited tic disorder commonly associated with other neurobehavioural conditions ..." —Porta et al. 2008, PMID 18544005
• "It is generally accepted that Tourette syndrome is inherited, but the genetic mechanisms appear more complex than they previously seemed to be, as evidenced by recent studies." —Robertson 2005, doi:10.1383/psyt.2005.4.8.92
• "Despite evidence that TS is an inherited disorder, the exact genetic abnormality is unknown." —Singer 2005, PMID 15721825

• In general, older sources tend to be more conservative in their assessment of whether TS is inherited, as its etiology wasn't known as well back then. The current consensus, however, is that TS is inherited, though (as with many other inherited conditions) environmental factors can also play a role.

Eubulides (talk) 20:00, 1 April 2009 (UTC)

The sources sited don't trump the ultimate authority, which is the DSM. As stated the DSM exists separately from medical text because the conditions listed cannot be traced back to biological sources.

A condition like Alzheimer's has many features of a mental illness, yet it's not in the DSM and that's because there's very strong evidence that it's in fact physiological. Meanwhile, there's no direct evidence for this disorder or any in the DSM or else it would be removed.

It's simply how the DSM works and if anyone doesn't believe this, then clearly they haven't studied the book or how to diagnose mental illness.

Psychotherapy: http://ajp.psychiatryonline.org/cgi/content/full/160/6/1175 This study suggests that psychotherapy may affect symptoms of Tourette's. Psychotherapy is considered unethical when applied to a medical condition. One must order a full medical work up from a doctor before one engages in therapy to reduce or eliminate the symptoms of a mental condition. The main goal of most therapies is "personality reconstruction" and to apply that idea to a condition which is beyond control, such as acne, for instance, would be heinous. Clinicians aren't heinous for treating Tourette's, rather they're acting on the possibility that the condition is behaviorally induced somehow.

Causation: The above response to the causation discussion makes no sense. Perhaps the poster should expand on it. —Preceding unsigned comment added by 69.253.247.185 (talk) 23:11, 1 April 2009 (UTC)

Nope, I agree with Eublides and Sandy. The DSM is a diagnostic manual, not an argument in favor of a disorder's being biological or not. The mainstream view is that TS is a neurological disorder, but that environmental factors also play a role in its etiology (and as far as I know, that's roughly the view for a large number of physical and mental illnesses...the case is just as messy with schizophrenia, OCD, depression, bipolar disorder, etc.—they all have both biological and environmental factors). In any case, the article's current wording is already quite clear about the fact that both biologican and environmental factors have been implicated in TS, so I still don't see what the disagreement here is. rʨanaɢ ^talk/_contribs 23:22, 1 April 2009 (UTC)

Whether you agree or disagree isn't important. The American Psychological Association which is made up of a huge assortment of psychological and medical professionals spend years determining what is and isn't a mental problem, what should be considered so, what is in other cultures versus the West, and so forth. It's after careful consideration that Tourette's, and all of the other conditions you mentioned, are seen as likely psychological in origin because they don't have clear medical origins. It's not for you to decide these facts, and they are facts.

You Said: "biologican and environmental factors have been implicated in TS". The article clearly says that the condition "is" an inherited neurological condition, and that's not a fact. It's not what the authority on the subject thinks and quite frankly it's odd to keep minimizing and avoiding that fact. —Preceding unsigned comment added by 69.253.247.185 (talk) 01:38, 2 April 2009 (UTC)

"Whether you agree or disagree isn't important" ... actually, Wikipedia works by consensus, so what people agree on is the only thing that's important. rʨanaɢ ^talk/_contribs 01:50, 2 April 2009 (UTC)

And on a side note...I'm not an expert in all these conditions, but your claim that schizophrenia is "seen as likely psychological in origin because [it doesn't] have clear medical origins" is simply false. While no one has identified a single (either biological or environmental) cause for it, everyone recognizes that there are biological factors; there is an enormous body of research about the neurobiological correlates of schizophrenia symptoms. (And I'm not referring to out-of-date ideas, either; I just attended a talk on this very stuff a couple weeks ago, so trust me, it's still an active area of inquiry.) The more say, the more I'm getting an impression that your claims do not reflect an understanding of what TS and other disorders actually are, but rather reflect what you think they should be. rʨanaɢ ^talk/_contribs 02:07, 2 April 2009 (UTC)

(outdent) I'm afraid that it's hard to take seriously a comment claiming that Wilhelm et al. 2003 (PMID 12777279) "suggests that psychotherapy may affect symptoms of Tourette's", when what Wilhelm et al. actually wrote was that in their study psychotherapy "did not seem to have an effect on the severity of the disorder". I also find it hard to take seriously a claim that the DSM is the "ultimate authority". It's not the ultimate authority on every subject. It is a diagnostic manual, and it deliberately is not a reliable source on causation. If you want to establish a claim about causation, you need to cite reliable sources on causation, not the DSM. Such sources include (but are not limited to) Stillman et al. 2008 (PMID 19105198), Porta et al. 2008 (PMID 18544005), Robertson 2005 (doi:10.1383/psyt.2005.4.8.92), and Singer 2005 (PMID 15721825). Eubulides (talk) 05:24, 2 April 2009 (UTC)

This thread got into WP:NOTAFORUM territory when Leslie Packer's personal website was misrepresented to claim a connection between TS and Passive-Aggressive Personality Disorder; without some specific reliably sourced proposed changes, it's hard to see much use for this thread. SandyGeorgia (Talk) 05:52, 2 April 2009 (UTC)

Examples:

Firstly, links posted about alternate theories regarding the cause of Tourette's were simply to illustrate that there are indeed alternate ideas, as much as that may offend you, for whatever irrational reason. Secondly, and most importantly, without the DSM classifying this condition as a condition, it would not be a condition. So, attempting to argue against its authority on the topic is childish.

Frankly, most of the responses here have been childish, poorly informed, or both.

One doesn't need to post linking regarding "causation" as it applies to scientific studies unless one plans on posting that info in every single wiki article having anything to do with study. The DSM states that no causal link can be established to any dysfunction, so that concept is built directly into every discussion about every recognized disorder.

I get the feeling that most of you responding aren't clinicians and are making up rules as you go. The article misinforms the public by virtue of one single sentence which should be changed and there's really no two ways about it. —Preceding unsigned comment added by 198.184.150.254 (talk) 11:37, 2 April 2009 (UTC)

Please don't throw insults on the talk page. Your claim that the DSM does not list conditions with a known physical cause is false. The DSM lists dementia in all its variants (Alzheimer, Vascular, Creutzfeld-Jacob disease, etc.) It lists degrees of mental retardation. It lists disorders due to various substance abuses. It lists Autism and Narcolepsy, neither of which are considered to have a psychological cause. Colin°^Talk 12:09, 2 April 2009 (UTC)

It lists "Dementia of the Alzheimer's type 294.1x" which isn't saying that it's directly Alzheimer's with a known cause. For instance, there's no such thing as "Fatigue of a Diabetes Type," because it either is or is not Diabetes. Alzheimer's is thought to be caused by one thing, but some kind of poison could have caused it, or an undiscovered history of drinking for instance.

Get it?

Mental retardation can be caused by oxygen problems at birth, genetic defects due to inbreeding, other genetic facts, or things which no one has a clue about. Again, there is no fixed cause. If there was it wouldn't be in the DSM.

It says that at the beginning of the DSM, and it's there for a reason. The reason is so that all angles of a problem can be explored. —Preceding unsigned comment added by 198.184.150.254 (talk) 12:25, 2 April 2009 (UTC)

Epilepsy is not in the DSM yet seems to fit your criteria for inclusion: there are multiple causes, most of which we don't really understand; it affects the brain/mind. Colin°^Talk 12:35, 2 April 2009 (UTC)

Colin,

Doctors can monitor the brain of an Epileptic and actually see what's going on with brain waves when a seizure happens. That puts it into the medical realm instead of giving it the possible label of an odd attention getting behavior.

Quotes:

DSM-IV-TR

Nonclinical decision makers should be cautioned that a diagnosis does not carry any necessary implications regarding the causes of the individual’s mental disorder or its associated impairments. Page xxxiii

Tourette’s Disorder may constitute a specific type of Obsessive-Compulsive disorder. Page 112. —Preceding unsigned comment added by 198.184.150.254 (talk) 15:23, 2 April 2009 (UTC)

Actually few doctors (including neurologists) see their patients having seizures let alone get the chance to record them on EEG. And seeing an EEG doesn't tell you why they are having a seizure any more than seeing someone's damaged brain on an MRI tells you why they got Alzheimers. Many (perhaps most) cases of epilepsy are idiopathic in the same way that Tourettes is -- we can give no explanation for it but often we think it has a genetic component because we see it run in families. Truly there isn't a firm rule for inclusion in the DSM, and we've given plenty examples of conditions in the DSM which are "biological and run in families", which is the attribute you objected to. Your belief that "The DSM is for unexplained problems which seem to stem from the mind" is busted for nobody thinks mental retardation or Alzheimers "seems to stem from the mind". Me thinks you are trolling.... Colin°^Talk 16:39, 2 April 2009 (UTC)

Trolling is right on the mark. In particular, 198.184.150.254's comment that doctors can "actually see what's going on with brain waves" belies a great misunderstanding of what EEG is and what it can and can't tell you. I don't think this discussion is going to go anywhere or result in any changes to the article, so there's probably not much point responding anymore...hopefully if we are all quiet then we can stop going in circles. rʨanaɢ ^talk/_contribs 16:43, 2 April 2009 (UTC)

1st cut at an Epidemiology rewrite

In my sandbox I made a first cut at a rewrite of Tourette syndrome #Epidemiology, along the lines suggested in #Recent reviews by Robertson, by Bloch, etc. above. It still needs a lot of work, but I just wanted to make a snapshot of what I've done so far. One thing this snapshot does, which I hadn't anticipated, is move some discussion of comorbid conditions out of Tourette syndrome #Characteristics into Epidemiology. Strictly speaking, a comorbid condition is not a characteristic, so there's some justification for the move; but I thought I'd mention it here. Eubulides (talk) 07:40, 11 April 2009 (UTC)

Thanks for doing that, since I've been sidetracked. I have to pr/ar FAC today, but will look at it as soon as I'm done. SandyGeorgia (Talk) 15:15, 11 April 2009 (UTC)

The rewrite is excellent! I have only one comment:

• Among Tourette's patients whose symptoms are severe enough to warrant referral to clinics, ...

Later in the text, the wording "tertiary care of specialty clinics" is included; can we move that in to here as well to distinguish from those children who are seen in a regular medical clinic and may not tend towards the comorbids found in tertiary settings? Thank you so much for doing that work, Eubulides. SandyGeorgia (Talk) 17:23, 11 April 2009 (UTC)

Thanks; the cited source says "specialty GTS clinics", not "tertiary care", so I changed that to read:

• "Among patients whose symptoms are severe enough to warrant referral to specialty Tourette's clinics, ..."

and then installed it. I still view this as a first cut, but haven't had time to do the rest yet. I'll suggest a draft of the next cut here first. Eubulides (talk) 07:09, 13 April 2009 (UTC)

I've just had a quick look and have a few comments. Some of these might not be new issues...

• I'm a bit uncomfortable with interspersing figures from high-quality papers with those from the NINDs factsheet.

• I agree (as Eubulides said, this is the first cut, and I've been lax in helping out because, as usual, I've been pressed for time). The Robertson papers have numbers on tic disorders that we can use to replace the old NIH factsheet numbers. SandyGeorgia (Talk) 13:36, 13 April 2009 (UTC)

• An attempted fix is in #Update to 1st cut proposal below. Eubulides (talk) 05:59, 20 April 2009 (UTC)

• The factsheet is used to say "as many as 1 in 100 people experience tic disorders, including chronic tics and transient tics in childhood." which I read as an upper bound of 1% for all tic disorders, including TS. Yet later we use Robertson's 1% "overall international GTS prevalence figure".

• Robertson is good, NIH is outdated. (This has always been true, but we finally have one paper that lays it all out.) SandyGeorgia (Talk) 13:36, 13 April 2009 (UTC)

• Agreed that NIH is outdated; #Update to 1st cut takes this line too. Eubulides (talk) 05:59, 20 April 2009 (UTC)

• The sentence beginning "Using year 2000 census data" should be split in two as it is currently confusing: I first read the second half as a UK version of the US data and was confused why only the upper bound was used. Then I realised the UK example was using Robertson's 1% "everyone" figure rather than the 0.1–1% childhood figure used for the US data. I think we need to clearly separate prevalence figures for children from those for everyone as that seems to be what our sources do.
• Hmm, I see from your discussion above that Robertson's 1% figure was based on studies of children 5-18 years old. Although Robertson's abstract calls the 1% an "overall international GTS prevalence figure" perhaps this is qualified with an age range in the article? Is the UK census data based on everyone 5 years and older?

• She combines known data to the 1% overall. SandyGeorgia (Talk) 13:36, 13 April 2009 (UTC)

• Robertson assumes that GTS doesn't go away, basically; this is a major assumption and #Update to 1st cut tries to address this. Eubulides (talk) 05:59, 20 April 2009 (UTC)

• Roberton's abstract (I don't have the paper) gives figures of 0.4% and 3.8% as the range for prevalence in school-age children. This is higher than the 0.1 to 1% we give. It appears, to an outsider and non-expert, that we may be arbitrarily picking figures from random papers :-). Shouldn't we try to take them from one source so they are consistent?

• They are consistent; we may need to work on the wording. I'll wait until Eubulides has time to get to the next cut. SandyGeorgia (Talk) 13:36, 13 April 2009 (UTC)

• The 0.4 to 3.8% range is what Robertson says "has been reported to be" by various sources; the 1% is Robertson's "representative accurate overall figure". Eubulides (talk) 05:59, 20 April 2009 (UTC)

Colin°^Talk 08:25, 13 April 2009 (UTC)

Update to 1st cut

In my sandbox I made an update to the 1st cut, which tries to address the points raised by Colin above. (This isn't really the 2nd cut, which will rewrite a good chunk of the last paragraph of Epidemiology; it's just a fixup of the 1st cut.) Here's the proposed change, omitting changes to citations:

"... thus, assuming a diagnosis may no longer be warranted for many adults, and prevalence is much higher among children than adults, whereas assuming adults tend to retain Tourette's with milder symptoms but increased psychopathology, prevalence is roughly the same in both groups. Children are five to twelve times more likely than adults to be identified as having tic disorders; as many as 1 in 100 people experience tic disorders, including chronic tics and transient tics in childhood, and it appears that 7–28% of the population at any given time has motor tics, depending on age, gender, and season. The emerging consensus is that 1–10 children per 1,000 have Tourette's, with several studies supporting a tighter range of 6–8 children per 1,000. Using year 2000 census data, a prevalence range of 1–10 per 1,000 yields an estimate of 53,000–530,000 school-age children with Tourette's in the US, and a the higher prevalence estimate of 10 per 1,000 means that in 2001 about 553,000 people in the UK age 5 or older would have Tourette's."

The basic idea here is to give both Robertson's and the Yale Tic Severity's estimates, and to drop the NIH's estimates. The two estimates don't agree, and the text gives them both. Eubulides (talk) 05:59, 20 April 2009 (UTC)

The "it appears that" comes across a bit weasly; not sure how to fix that, perhaps with attribution? Also, some lesser experienced readers may still be confused, as they may not get that the text switches from talking about TS to talking about tic disorders; can some of the deleted wording specifying the difference be worked back in? Also, "increased psychopathology" could be confusing to less experienced readers, as we haven't really defined that previously. SandyGeorgia (Talk) 13:40, 20 April 2009 (UTC)

Planned translation into Russian

Hello! I wish to translate the article for RuWiki. Is the article "stable" enough or should I wait a week or two? --CopperKettle 13:19, 19 April 2009 (UTC)

It's very stable, it hasn't had any major changes in weeks, and it is semi-protected. (But I am not one of the main contributors to this article, so if you want a more "official" response you should wait to hear from SandyGeorgia or Eubulides).rʨanaɢ ^talk/_contribs 13:46, 19 April 2009 (UTC)

SandyGeorgia is the expert here, but I think the article's quite stable. I have some rewriting of the Epidemiology section on my plate (please see #1st cut at an Epidemiology rewrite above) so I suggest translating that last. Eubulides (talk) 18:26, 19 April 2009 (UTC)

Right ... and the lead last, since it may need a minor tweak to accomodate new Epidemiology. SandyGeorgia (Talk) 19:39, 19 April 2009 (UTC)

O.K., I'll wait till May. --CopperKettle 03:52, 23 April 2009 (UTC)

New study of prevalence of diagnosed TS in US

A new study is out re prevalence of diagnosed TS in the US:

• Scahill L, Bitsko RH, Visser SN, Blumberg SJ, "Prevalence of diagnosed Tourette syndrome in persons aged 6–17 years—United States, 2007". MMWR Morb Mortal Wkly Rep. 2009 Jun 5;58(21):581–5. PMID 19498335

It's just a primary study, so I'm not sure whether it's worth mentioning in the article, but I thought I'd mention it as it's making the rounds. Eubulides (talk) 08:18, 8 June 2009 (UTC)

Web link fixes needed

The link checker reveals that two links redirect to their home pages. Can someone fix this? Dabomb87 (talk) 00:29, 10 August 2009 (UTC)

Thanks Dabomb: I'll get on it now. SandyGeorgia (Talk) 00:31, 10 August 2009 (UTC)

Grrrr on what we went through with those mindsite folks. That also needs to be replaced at Major depressive disorder, sleep, and polysubstance dependence. SandyGeorgia (Talk) 00:52, 10 August 2009 (UTC)

Where to put full versions of abbreviated citations

Re this edit, which I mostly reverted. I've run into similar problems elsewhere, where a few works are cited many times, and it's useful to collect the the full citations into a section, and to have the footnotes cite these works in abbreviated form. In Daylight saving time I addressed the problem by moving those books into the Further reading section, which isn't exactly appropriate, as Further reading is supposed to be for books that weren't used as sources; I attempted to work around the problem by having the first footnote mention the existence of the full citations in the Further reading section. In Philitas of Cos I addressed it by renaming the section that is ordinarily called References to Notes and having a new References section containing the list of full citations; but it's a bit weird and non-uniform to have the section title move to the newly-added section when you need the new section. I vaguely recall seeing an list-of-full-citations section called Bibliography in some other article but that's not appropriate either, as the MOS says that Bibliography is for works written by the subject of the article. I don't know of any useful guideline in Wikipedia in this problematic area. The approach currently taken in Tourette syndrome #References isn't clearly wrong, and is arguably better than what's in Daylight saving time or in Philitas of Cos, not only because it doesn't abuse Further reading and References as titles, but also because it puts the most important references first. Eubulides (talk) 13:24, 26 August 2009 (UTC)

I posted my thoughts at user talk:Eubulides#Tourette syndrome. I don't have strong feelings either way – my original edit was simply a "fixing" of what I construed to be strange and out of the norm. An article that uses the format I inserted is Quark. As one of the article's authors, I know the fact that we have "Notes", "Citations", "References" and "Further reading" was never a concern in any of the article's umpteen reviews. —Anonymous Dissident^Talk 13:30, 26 August 2009 (UTC)

Struck some – what I said was erroneous (my memory is fraying after all). —Anonymous Dissident^Talk 13:35, 26 August 2009 (UTC)

See WP:CITESHORT. The approach used in Philitas of Cos (and many, many other articles) is the one currently recommended. I personally see no rationale for the one used in TS right now. Fvasconcellos (t·c) 13:33, 26 August 2009 (UTC)

Ah, thanks, I guess I must have read WP:CITESHORT before doing Philitas of Cos and then forgot WP:CITESHORT's existence. Well, I don't like the fact that it renames References to Notes but I guess that it's a better guideline than nothing at all, so I gave it a whirl for this article. Eubulides (talk) 13:53, 26 August 2009 (UTC)

Link

Good afternoon

I am writing to request a link to my web site on Tourette Syndrome. I am an individual on a non profit basis. I am trying to raise awareness of Tourette Syndrome through the site by letting sufferers share their own experiences. The site also has articles to access (still growing) and a live chat facility. I am trying to optomize the site to raise awareness. Could you please consider adding a link to my site from your article on TS. The url is http://www.tourettesyndrome.eu. You can email me at info@tourettesyndrome.eu

Thank you so much 86.134.158.157 (talk) 11:04, 30 November 2009 (UTC)

Thank you for asking. We have a policy on external links here. Unfortunately, your web site fails a number of the rules in the "Links normally to be avoided" section of that policy. I hope you understand that if we included every worthy website that aimed to help people with a particular medical condition, our articles would be swamped by a very long list of links. I hope your website is successful. Regards, Colin°^Talk 12:57, 30 November 2009 (UTC)

Tourette syndrome in the media

Many Wikipedia pages include a section about how the topic of the page is presented in the media. I came to this page looking for information because of a film I saw which was about a child with Tourette syndrome, so I thought I might as well throw out the possibility of including an "in the media" section on this page. The film that I saw was "Phoebe in Wonderland" and it shows a side of Tourette syndrome that was completely new to me. Pros and Cons? SirenDrake (talk) 14:51, 25 January 2010 (UTC)

There's already a whole article on this, Sociological and cultural aspects of Tourette syndrome. rʨanaɢ ^talk/_contribs 14:53, 25 January 2010 (UTC)

And, already linked and mentioned:

* The entertainment industry often depicts those with Tourette syndrome as social misfits whose only tic is coprolalia, ...

SandyGeorgia (Talk) 15:00, 25 January 2010 (UTC)

Missed that. My bad. SirenDrake (talk) 19:07, 25 January 2010 (UTC)

Diseases with no known cure

I agree with the reverting of this edit, which added Category:Diseases with no known cure. Even if we agreed that TS is a disease, that category is trivial and unencyclopedic. I've nominated that category for deletion at Wikipedia:Categories for discussion/Log/2010 February 26 #Category:Diseases with no known cure. Eubulides (talk) 23:10, 26 February 2010 (UTC)

New article

Most of the dates in this article diagree with dates in Wiki articles (birthdates, death, ages, etc., Itard, GTS, etc.), but I'm unsure if that's a discrepancy between old-style dates and current calendar, as in Samuel Johnson. This article can be used to expand Itard, Charcot and Gilles de la Tourette, but I don't know what's going on with the dates. SandyGeorgia (Talk) 00:27, 27 February 2010 (UTC)

Picture

Shouldn't the picture be of a person with Tourette Syndrome, instead of the guy who identified it? Obviously there's potential for this being embarrassing/insulting if a picture of someone experiencing tics is used for humorous effect--but I'm sure there are some people with Tourette's who would be okay with having a picture of them ticcing, and could suggest one that they like. —Preceding unsigned comment added by Gorramdoll (talk • contribs) 16:57, 6 March 2010 (UTC)

It would have to be free content, of a notable person; we don't have one of those. SandyGeorgia (Talk) 17:01, 6 March 2010 (UTC)

A tic is an action, it can't be shown in a single picture. What you're looking for is a video. However, since there are many different kinds of tics (really, nearly everyone with TS has their own tics), there's no real way to decide which one should be illustrated. And I don't know of any place that has a freely-available video anyway. rʨanaɢ ^talk/_contribs 17:03, 6 March 2010 (UTC)

Videos of tics are already linked in the article ... see the "Clips of tics" box :) SandyGeorgia (Talk) 17:04, 6 March 2010 (UTC)

It'd be great if there was a free video of a tic that the article could use. It's not a problem that editors would have to decide which one should be illustrated: right now, we'd be happy if we could have even one video. Articles like Asperger syndrome have managed to scare up a free image that is reasonably representative; it's harder to do so for this article, but if it could be done, we should use it. Eubulides (talk) 20:03, 6 March 2010 (UTC)

OGG = 140 kb

Would this be appropriate? Anthony (talk) 19:19, 11 March 2010 (UTC)

Yes if the individuals pictured don't mind. The current picture of Georges Gilles de la Tourette doesn't work at all, but there was no alternative. -SusanLesch (talk) 19:24, 11 March 2010 (UTC)

I clipped it from I have Tourette's but Tourette's doesn't have me - a DVD produced by Tourette Syndrome Association, Inc. and HBO in 2005. It was supplied to me by Tracy Colletti-Flynn, Manager, Public Relations and Communications, Tourette Syndrome Association, Inc. We can insert it once I get confirmation she has emailed the Creative Commons declaration to permissions-commons@wikimedia.org, which is immanent. A portion of the documentary is linked to in the "Clips of tics" box SandyGeorgia referred to. If you think another tic or other tics in the video would be better, I could remake the GIF and I assume Tracy would license it. Anthony (talk) 19:53, 11 March 2010 (UTC)

If you have the TSA on board, and are working on getting permission, I'll rewatch the full documentary, looking for the most common tics ... SandyGeorgia (Talk) 20:55, 11 March 2010 (UTC)

Wow, this is a great development! Thanks. I hope it works out and am looking forward to a much better illustration or illustrations in the article. Eubulides (talk) 21:07, 11 March 2010 (UTC)

Tracy's last email on 12 March said "I will send you the (Creative Commons license)... Is a digital signature/name ok?" But she may need to clear it with someone first. Anthony (talk) 09:02, 13 March 2010 (UTC)

Anthony, are Tracy and you set on this particular clip, or could you ask her to include some more common, subtle tics? Those are what most frequently go misdiagnosed, and will help reader understanding. Perhaps two clips? This one is very good, but includes rather pronounced tics, rather than more common, subtle ones. TSA is well aware of the problem of sensationalizing tics, so I hope Tracy will understand what I'm referring to. You've done very nice work ! SandyGeorgia (Talk) 12:27, 13 March 2010 (UTC)

I chose them beacuse they were head shots and next to each other; whatever you think appropriate is fine with me. And I'm pretty sure Tracy will be okay with anything we select. It should be short, though, to keep the file size and loading time down. I could splice a couple of 1 or 2 second clips together. What did you have in mind? Anthony (talk) 16:17, 13 March 2010 (UTC)

I haven't found time yet to rewatch the documentary ... meaning, I haven't figured out how to replay my TIVO :) Do you have it handy? Anything simple like nose scrunching, eye blinking, shoulder shrugging, hair tossing ... some very simple tics to go along with what you already have. This is going to be a huge improvement in the article ! SandyGeorgia (Talk) 16:20, 13 March 2010 (UTC)

How about this? Anthony (talk) 17:53, 13 March 2010 (UTC)

I like the new one even better. Thanks again. Eubulides (talk) 01:13, 14 March 2010 (UTC)

I'm on dialup and generator power after a big storm, and the clip doesn't play. Is there anything we can do, technically, about that, since half the world is on dialup? I do see it now features Colin, but I shouldn't play favorites ... if I did, it would also include Augeni (sp?), the curly-headed Shirley Temple dancer :) What I'm after, Anthony, considering most TS diagnoses in children are missed, is a clip that will make readers looking for info about TS for the first time say, "Wow, that's what my kid does, maybe it's tics", instead of, "My kid doesn't do anything that extreme, it can't be TS". It's the common, routine tics that's parents can write off to allergies, nerves, whatever that more often go misdiagnosed; the more pronounced tics are more easily recognized. I can't tell if your clip does that until I get my cable modem back. Thanks for all the work on this! SandyGeorgia (Talk) 09:27, 14 March 2010 (UTC)

No hurry. Let me know when you've had a chance to view the clip. Meanwhile, I'll see if I can make it more dial-up friendly. Like you, I think Wikipedia pages should be small and fast enough for dial-up - if possible. This is the first time I've done anything like this, though; so I don't know what's possible. Try right-clicking the image, saving it to your desktop ("save image as", on dial-up it might take a minute to download) and clicking it. Anthony (talk) 10:11, 14 March 2010 (UTC)

Hmm, on second thought, I hadn't thought about the size (I have a fast connection). That's a real problem, and I suppose we should limit the image to one or at most two tics, and let the user click on something to see a bigger (longer) image. Or how about generating an Ogg file instead? That should help with the problem of size, no? See Commons:Video and Wikipedia:Creation and usage of media files #Video. Eubulides (talk) 19:43, 14 March 2010 (UTC)

Thanks. I'll play with it tomorrow. Anthony (talk) 20:28, 14 March 2010 (UTC)

I'd support generating an Ogg or whatever Wikipedia supports best. In addition to smaller size, the image quality should be vastly improved. Plus you have the possibility of sound and the reader has the ability to start/pause, which is very important IMO. I find the animated GIFs on Wikipedia to be very distracting when trying to read the content next to them. I'm glad we have the chance to get a video embedded here rather than a link offsite. If you have any difficulty with the Ogg format, I'm sure there are editors on Wiki that have the expertise to help. Colin°^Talk 20:35, 14 March 2010 (UTC)

I can't comment, and can barely read Wiki-- may have cable modem back by tomorrow-- utilty companies working all over town. SandyGeorgia (Talk) 20:37, 14 March 2010 (UTC)

Thanks Colin. I didn't even know Wikipedia supported embedded video. I don't get around much, This will be fun. Anthony (talk) 20:44, 14 March 2010 (UTC)

This is OGG. They are smaller files than the GIF, so should load faster. Thoughts? (Can you see these, Sandy?) Anthony (talk) 13:25, 16 March 2010 (UTC)

arrrgh ... "You do not appear to have the XiphQT component for QuickTime. QuickTime cannot play Ogg files without this component. Please download XiphQT or choose another player." I don't know how people put up with me :) I don't look forward to downloading something while on dialup :) SandyGeorgia (Talk) 13:45, 16 March 2010 (UTC)

Half a mo'. I have the bitrate wrong. "...a bitrate of no more than 220 kilobits/sec will work for users of 256 kilobit DSL. Very high bit rates near or over 1,000 kilobits/sec may outstrip the ability of Wikipedia or the Commons to deliver the streaming data fast enough." These are 1,200. Sorry for the anguish. I'll be back. Anthony (talk) 14:47, 16 March 2010 (UTC)

How are these? Anthony (talk) 16:28, 16 March 2010 (UTC)

I still can't play them. I tried to download (something), but my connection is too slow-- I'll have to go to the libary, since cable isn't restored yet. Thanks for hanging in there, Anthony, and I'm sorry for my limitations. SandyGeorgia (Talk) 16:39, 16 March 2010 (UTC)

Both OGGs work just fine for me. But I'm using a good browser (Firefox) with a fast connection, so perhaps I'm not the best guy to ask. Eubulides (talk) 07:10, 17 March 2010 (UTC)

I've removed the GIF so this page loads faster. Anthony (talk) 13:52, 17 March 2010 (UTC)

Whew, thanks for the patience. I downloaded the components I needed from a faster connection at the library, and then came home to play them on dialup; both are fine, but the top one loads faster. Dumb question: why don't they have sound? SandyGeorgia (Talk) 20:26, 18 March 2010 (UTC)

The voice-over is all chopped up because I've grabbed tiny clips from different parts of the video; and sound makes the file bigger - slower to download. Both clips look the same to me, too, so I'll remove the bigger, slower one. Anthony (talk) 21:06, 18 March 2010 (UTC)

Permission from TSA

Tracy has forwarded permission to the WP copyright people. Thank you for nudging her, Sandy. Can you compose a caption, if you think it needs one, and let me know where you'd like it to go, please.? I can move the still on a few frames, if you'd like the boy's eyes open. That's just a random frame chosen by the edit program. But there may be something in favor of this mid-blink still. Anthony (talk) 06:57, 23 April 2010 (UTC) Actually, you mentioned you know some image people. It may be better to get an expert to insert it and get it right (I don't know the guidelines, if any), but if you'd like me to give it a shot, I'd be happy to. Anthony (talk) 07:08, 23 April 2010 (UTC)

I've queried Jappalang; I've never dealt with uploading images. SandyGeorgia (Talk) 12:37, 23 April 2010 (UTC)

I've gone ahead and added it to the article; is this what you were looking for? (If not, feel free to revert.) It still needs alt-text added, that works the same as it would for a regular image (|alt= ...). rʨanaɢ (talk) 14:49, 23 April 2010 (UTC)

I'm not that clear on whether it already has OTRS clearance. SandyGeorgia (Talk) 14:52, 23 April 2010 (UTC)

Oops, sorry, I hadn't noticed that. It looks like it's still waiting for clearance; I've commented it out in the article for now. rʨanaɢ (talk) 14:57, 23 April 2010 (UTC)

Hi Sandy. I just looked at the dif. of the clip on the page. On my screen it comes up quite large for a low resolution clip. But perhaps that's just my settings. Anthony (talk) 16:17, 23 April 2010 (UTC)

That's the default size of the file. It used to be the case that we weren't supposed to force size for videos embedded in articles, although I'm not sure how things are now. It was discussed briefly at User_talk:Rjanag/Archive8#video and WT:FA#Videos. rʨanaɢ (talk) 18:46, 23 April 2010 (UTC)

If the OTRS goes through, the clip would have no issues on the copyright/permission front (since presumably the producers would be holding the copyright of the video).

There is concern about personality rights, though (hence the tag). The production may have consent from the patients and families to be recorded for the video (for educational purposes), but not for other intent. I am not certain if the producers have received clearance from the subjects to be used for other purposes. When the license is "The copyright holder of this file allows anyone to use it for any purpose", I am worried. While we can control/mitigate inappropriate use of the media here on the project (and revert awful hurtful vandalisms), the expressed copyright release would allow the clip for certain distasteful derivative productions (or portrayal in an inappropriate context)... Licensing it under Creative Commons would have provided an underlying binding for moral rights (right to integrity) to the copyright holders (which I think would at least help to deter misuse of the clip in the US), so I am not sure if attribution-only is the correct path for the licensing of this media.

Nonetheless, the project is mostly concerned with copyrights alone, and if the producers chose to do this, then so be it. I added the personality rights to warn potential re-users that they have to contact the copyright holders, hopefully allaying any misuse.

I think embedding the video in the article in "thumb" form is okay... The quoted section in the video creation guide is only an opinion in my view—basically stating an inefficient implementation. As long as it does not crash browsers or systems, it would be fine. Still, it is wise to follow the opinion there and re-encode the clip for a smaller resolution/size and use it instead. Jappalang (talk) 01:35, 24 April 2010 (UTC)

Another way to make it smaller without (I think) uploading a new version of the clip is to hack a table, like the example here. rʨanaɢ (talk) 03:52, 24 April 2010 (UTC)

Jappalang raises an issue that was recently discussed (with no clear resolution) at Wikipedia talk:WikiProject Medicine/Archive 17#Patient images: consent issues. If the film-makers received consent (model release) for the images to be used for education purposes or perhaps solely by the TSA, then that consent does not extend to WP Commons or Wikipedia. From my amateur reading on the issue, the publisher (not the photographer or film-maker) is liable to prosecution if those rights are broken. I'm not clear if the publisher is the uploader or Wikimedia Foundation. This is indeed a separate issue from copyright. The TSA should have some paperwork that clarifies what those kids or their parents signed and the extent of any permission given. Colin°^Talk 09:29, 24 April 2010 (UTC)

This is a little out of my depth. I think we need an opinion from Wikipedia legal. If we have the right to post the clip, I would sleep better if we had the approval of each child. (I believe this is definitely worth this effort, and a lot more.) Anthony (talk) 12:18, 24 April 2010 (UTC)

Are you in contact with the TSA? Could they tell us what the permission form the kids/parents signed said? I'm afraid that when I emailed Godwin (WP's legal bod) about a large donation of patient images (which turned out to be a misunderstanding), I got no reply. Colin°^Talk 14:57, 24 April 2010 (UTC)

It's a tricky situation, especially with minors involved, when most of them chose not to disclose their full identities. If you can get more specifics out of Tracy Flynn, I can e-mail User:Elcobbola and ask him to have a look-- he's a fantastic image person, but hasn't posted in a long time. I hope User:Jappalang-- another fabulous image person-- is still watching. SandyGeorgia (Talk) 15:39, 24 April 2010 (UTC)

I have emailed Tracy pointing out that once it appears on Wikipedia, the clip may be used and modified by others (with attribution) and asked her to double-check with the producer that this conforms with the release the kids signed. Anthony (talk) 23:16, 24 April 2010 (UTC)

Permission for use of this clip has been verified by OTRS. I have fewer reservations about this because I've noticed the DVD is copyright 2005, so the kids are more grown up now, and everything in our clip is on the clip hosted on the TSA website. Anthony (talk) 19:29, 26 April 2010 (UTC)

I'm a bit uneasy as well ... let's ping Jappalang and see what he thinks? Protective of these kiddos ... SandyGeorgia (Talk) 19:36, 26 April 2010 (UTC)

Well, the change of licensing to CC-BY-SA helps (at least TSA can attempt to assert moral rights if someone misuses the clip even with attribution). On the copyright/permission ground, the clip satisfies the project's policies/guidelines. As Colin pointed out, the project has not decided on the issues of patient's right, so that is not a point of contention here. Just keep a quick eye out for vandalism. Jappalang (talk) 00:14, 28 April 2010 (UTC)

Leckman in NYT

I think this would make a good External link here: anyone else?

• http://consults.blogs.nytimes.com/2010/03/12/coping-with-the-stigma-of-tourettes/?scp=1&sq=tourette&st=cse#preview

SandyGeorgia (Talk) 22:52, 14 March 2010 (UTC)

Pending changes

This article is one of a small number (about 100) selected for the first week of the trial of the Wikipedia:Pending Changes system on the English language Wikipedia. All the articles listed at Wikipedia:Pending changes/Queue are being considered for level 1 pending changes protection.

The following request appears on that page:

However with only a few hours to go, comments have only been made on two of the pages.

Please update the Queue page as appropriate.

Note that I am not involved in this project any more than any other editor, just posting these notes since it is quite a big change, potentially.

Regards, Rich Farmbrough, 20:42, 15 June 2010 (UTC).

PP.pending

100 articles were selected for pending changes since FA, GAs and stubs, the {{pp-pending}} won't "deface" the article, it is a notice for new users that all their edits not going to be public until a reviewer accept or not. Just because this have a small star does not deserve other privileges. Tbhotch^{Talk C.} 02:25, 18 June 2010 (UTC)

Pending changes template

Hi folks, I've reverted this article back to semi-protection while we discuss the use of the pending changes trial template at the top of the article. I can see both perspectives here; let's see if we can come up with a better solution that will be good for readers, potential editors and the encyclopedia. Risker (talk) 02:28, 18 June 2010 (UTC)

• I'll start: What about improving the edit notice so that it is large enough, and eye-catching enough, to draw the attention of a potential editor and advise them that their edit will be reviewed? Risker (talk) 02:30, 18 June 2010 (UTC)

• Question I only have one: In which way a general note could affect an article? Tbhotch^{Talk C.} 02:32, 18 June 2010 (UTC)

• • I don't have time to help sort this, Risker, but appreciate you popping in. Because of coprolalia-related vandalism, TS was semi-protected. I'm not opposed to being part of this trial, but adding a gross template to a stable featured article isn't a good thing. I trust those who have followed this issue more closely can come up with a better solution, or the article can remain protected and not part of the Pending changes trial. Wouldn't it be better for this discussion to remain centralized in the other page I posted on? SandyGeorgia (Talk) 02:33, 18 June 2010 (UTC)

• Part of the logic is that the big template says "come edit" rather than "don't edit", which the previous status of the article was. It'll likely go away once the two month trial is over, if not sooner. Hashing out of when it's going away might better be done on a more central page, because there are a few pages that will have this template. --Izno (talk) 02:39, 18 June 2010 (UTC)

Note: Discussion is now here. Risker (talk) 02:41, 18 June 2010 (UTC)

coprolalia

"Tourette's was once considered a rare and bizarre syndrome, most often associated with the exclamation of obscene words or socially inappropriate and derogatory remarks (coprolalia), but this symptom is present in only a small minority of people with Tourette's."

the german wikipedia page on coprolalia states that about 30% of tourette patients suffer from this. should it still be called a small minority?

The German page is wrong; see the sources here. I don't speak German, so I don't know what source they use, but it's probably a sample subject to ascertainment bias. From what I can tell of the sources used in the German article, it is a very poor article; it does not use any sources that would meet en.wiki's WP:MEDRS (and mostly relies on Oliver Sacks). SandyGeorgia (Talk) 19:44, 21 September 2010 (UTC)

Tourettes Karaoke

Hi, I suggest to include reference to Tourettes Karaoke video's as a demonstration of the symptoms and example of courageous coping with the disorder, what do you think about that? —Preceding unsigned comment added by 62.245.115.241 (talk) 01:06, 28 November 2010 (UTC)

Percussion instruement therapy

There has been some evidence that patients should be incuraged to partiscipate in the hobby of the playing of drums as a means of stress reduction, and thereby, ability to cope with daily mental challenges (citiation needed).--S-d n r (talk) 00:28, 29 January 2011 (UTC)

citation - "ref>http://www.google.com/search?hl=en&q=tourettes+syndrome+drum google search of drum playing therapy] </ref>."--S-d n r (talk) 00:47, 29 January 2011 (UTC)

Thanks, S-d n r. That's fascinating. We can't put it in the article yet because content in medical articles has to be supported by reviews from peer-reviewed journals, per this guideline. I've just searched the PubMed index (that lists most of the best journals) and it doesn't seem to be covered yet. --Anthonyhcole (talk) 01:06, 29 January 2011 (UTC)

That is not a source, it's google search results (and most of those results are not even relevant to what you are claiming). Also, please proofread your contributions (specifically, checking for spelling) before posting them. rʨanaɢ (talk) 01:08, 29 January 2011 (UTC)

Psychiatrist Self-Aggrandisment Syndrome

If "...so many people..." (as implied by the opening paragraphs of the article) have some form of Tourette Syndrome, why, therefore is it regarded as a "disorder", or a "syndrome"? Now, I know very little about psychiatric/neurolgical disorders, but it seems to me that in order for them to be regarded as a "disorder" they must be measured against some kind of supposed "sociatal norm", and hence deemed to be an "aberation". I'm also no kind of statistician, but it further seems to me that the more people per head of population that have this "disorder", the more like a "norm" it appears to be. Perhaps the concept of the "sociatal norm" is at fault....what level of "statistical significance" is applied in cases of Tourette Syndrome? 82.5.68.95 (talk) 02:28, 26 February 2011 (UTC)