View Full Version : Behavioral Intervention Therapy


Don S.
07-03-10, 02:05 PM
Perhaps matters are beginning to change for the better for those afflicted with Tourette’s Syndrome and for those who care about them. First we had the recent proposed contingent change in DSM-V to classify it under Anxiety and Obsessive-Compulsive Disorders (a change, alas, that I am not at all confident will occur), and now we have an extensive study published in the Journal of the American Medical Association (JAMA) which reports very encouraging results in regard to treating children (9-17) afflicted with TS using behavioral intervention therapy. The study’s lead author is Dr. John Piacentini, Professor of Psychiatry at the <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-comhttp://www.addforums.com/forums/ /><st1:PlaceType w:st=</st1:PlaceType>University of <st1:PlaceName w:st="on">California Los Angeles.</st1:PlaceName>
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I quoted Dr. Piacentini within my essay “Is Tourette’s Syndrome a Neurological Disorder—A Dissenting Viewpoint” from an article entitled “Making Sense of Tourette’s,” published by the American Association for the Advancement of Science (AAAS). In the article, Dr. Piacentini states:

“…[Tourette’s] Patients feel the need to tic and then experience relief when they do, thus reinforcing the neural circuits involved in that behavior. To break the loop, Piacentini and his colleagues have been experimenting with behavioral techniques.” [Science; Vol 305; 3 September, 2004]

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In my estimation, this clearly points to the habituating behavior evidenced by TS patients bred from repetition and subsequent reinforcement. They are defense mechanisms in accordance with classic obsessive-compulsive pathologies and are inherently psychological in nature as opposed to organic.

In an article regarding the JAMA paper which is prominently indexed on the home page of the Tourette Sydrome Association, it is reported that 52.5% of children treated with Comprehensive Behavioral Intervention for Tics (CBIT) evidenced significant improvement with symptoms. Most encouragingly, 87% of those patients who showed such improvement retained the benefits six months after the treatments ended attesting to the durable efficacy of CBIT.

Within the article, it is stated that CBIT entails:

“The CBIT therapy was based on habit reversal training that includes two concepts: tic awareness and competing-response training. Tic-awareness training teaches the child how to monitor themselves for early indications (including the urge) that a tic is about to occur. Competing-response training teaches the child how to engage in a voluntary behavior designed to be physically incompatible with the impending tic, thereby disrupting the cycle and decreasing the tic.”

Although I am very pleased that TSA seems to be far more receptive to behavioral therapy than previously, I must note with dismay that once again within the article TS is referred to as a “neurological disorder.” One must ask: would any oncologist treat cancer by instructing his or her patients to become aware of premonitory signs that a malignant tumor is about to occur and then avert such by mental concentration?

Nevertheless, it is most encouraging that TSA would not only bring attention to this most encouraging paper, but actually note that the study was performed in partnership with them!

Click to read the article at the TSA website:

http://www.tsa-usa.org/news/0510BehavIntervenEffective.html (http://www.tsa-usa.org/news/0510BehavIntervenEffective.html)

Logic
07-05-10, 09:42 PM
“…[Tourette’s] Patients feel the need to tic and then experience relief when they do, thus reinforcing the neural circuits involved in that behavior. To break the loop, Piacentini and his colleagues have been experimenting with behavioral techniques.” [Science; Vol 305; 3 September, 2004]

“The CBIT therapy was based on habit reversal training that includes two concepts: tic awareness and competing-response training. Tic-awareness training teaches the child how to monitor themselves for early indications (including the urge) that a tic is about to occur. Competing-response training teaches the child how to engage in a voluntary behavior designed to be physically incompatible with the impending tic, thereby disrupting the cycle and decreasing the tic.”

Half the time, I generally know when I'm about to 'tic' - you may be aware that I don't have a diagnosis of Tourettes, and probably never will get one either. My Doc suggested I read literature on 'Transient Tic Disorder' and left it at that. They come and go, but recently, they've been around more often than not.

I was thinking about your post yesterday evening, and I was trying to figure out what kinds of "voluntary behaviour designed to be physically incompatible with the impending tic" I could figure out and use for myself. Maybe you're not at liberty to share such information, but I couldn't think of any that would disrupt any of my tics.
They're all mostly complex, involving the large muscle groups and some I can control and hold-off, others just spring forth and I have little control over.
To reduce the impact of these large movements, I would pretty much have to engage in 'voluntary restraint' to stop/reduce the tic - I have experienced involuntary restraint, and noticed that the larger movements subside to much less severe ones when there is a negative association with them (sudden movements/'violent' gestures = restraint/punitive action), but to try and control the same movements in a non-punitive environment - I have no idea aside from to do what I already do, which is yet again, restricted to the privacy of my own home - I lie on the floor, face down and clasp my hands together behind my neck as that restricts head, neck, shoulder and arm movement.
That can sometimes break a 'chain' of tics, but I only do that if it's bad.

I can see the kids getting the assistance they need to engage in this technique, but I guess i'd be pretty much on my own to try it out.

Logic

Don S.
07-06-10, 10:42 AM
Logic:

The following book was co-authored by Dr. Piacentini along with other therapists in the field. It is really addressed to other therapists working with TS patients, but I believe it can benefit intelligent laypeople with TS. Here is its Amazon link:
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http://www.amazon.com/Managing-Tourette-Syndrome-Behavioral-Intervention/dp/0195341287/ref=sr_1_1?ie=UTF8&s=books&qid=1278425058&sr=1- (http://www.amazon.com/Managing-Tourette-Syndrome-Behavioral-Intervention/dp/0195341287/ref=sr_1_1?ie=UTF8&s=books&qid=1278425058&sr=1-)
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The price is sort of steep (about $33.00), but one is getting it from the metaphorical horse's mouth.

One of the (many) problems, in my opinion, in trying to maintain that TS is an organic (physical) illness is the very subjectivity in which it is defined. How many times has its definition been changed over the years? There is never a question as to whether, for example, cancer is cancer. It either is or it isn't. There is no subjectivity about it.
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In my opinion, the reason for such historical subjectivity regarding exactly what constitutes TS is that it is not a disease per se, but rather is an example of pathologizing personality traits. When, for example, does a person who has obsessive tendencies officially reach the point where he or she is diagnosed with OCD? When he or she just has to go back once more in the morning to make sure all the burners are off and the doors are locked? Twice each morning before leaving for work? Three times?

If your tics are truly just that, as opposed to a physical spastic disease such as Parkinson’s Disease, then I believe habit reversal will benefit you as much as anyone who has been officially diagnosed with TS. It’s simply a matter of degree.
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Best of luck to you and thanks for the reply.

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Logic
07-06-10, 08:40 PM
Cheers for your reply also; this sub-forum is pretty much abandoned most of the time. :)
I'll probably invest in the book as I'm transferring into a third year psychiatric/mental health degree in september to qualify as a RMN. Anything that makes good reading is welcomed. my Doc suggested it's 'just tics' and nothing more, as did a neurosurgeon and a psychologist whom I was sent to after they got worse early last year.

They've stabilised and that's that I guess. I'd love to reduce them though as I've got a hard enough time fitting in with the rest of the world as it is, let alone trying to hide multiple tics, and explaining to people that it really isn't funny...

Cheers again for the reply.

Logic

ginniebean
07-06-10, 08:51 PM
It's probably pretty important to be careful about all or nothing thinking. Neurological disorders are not the same things as diseases so comparing tics to cancer is going to lead you astray because that analogy will break down so fast that it's pretty much not useful.

ADHD is a neurological disorder, there are things which help including Behavioural intervention therapy, because certain interventions help us doesn't erase the neurological issues and the same goes for other neurological conditions like tics. The brain is an extremely interesting organ and a very unique one.

Becoming aware of the urge prior and developing a substitute response does not allow for the conclusion that tics aren't neurological in origin. What it does mean is that when well rested and at the top of your game you can use a method that helps to control the physical expression. You might note that the 'urge' is not what is being targeted with the behavioural intervention therapy but rather the action that follows.

This was not touted as a cure but more an effective method of helping a person develop a coping strategy.

Don S.
07-07-10, 10:05 AM
Logic:
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Congratulations on your educational achievements, and I wish you al the best in the pursuit of your degree and chosen career. You will bring a level of perception and empathy to the field that many others might lack. My own views towards TS, for example, were formulated by years of observation and reflection within the “laboratory” of my own mind.

The Amazon page I linked to for the book I referenced contains a lengthy description of the authors’ work and their philosophy. I particularly commend to you and all their note that they encourage breathing exercises and other relaxation techniques to combat anxiety, which is precisely what my older character counsels to a twelve-year-old boy with TS and ADHD within “Pride’s Prison,” my free access short story which is a thinly-veiled personal memoir of my Catholic parochial school days growing up with a relatively mild case of TS and a more severe case of ADHD. (The diagnoses of ADD and hyperactivity were not yet formulated then, but please believe me that I could have been the poster boy for ADHD!)

My theory concerning all mental health afflictions which once might have been collectively described as “neurotic” is that they stem from what I refer to as “acute self-awareness,” an evolutionary process in which the innate animal instinct of self-preservation becomes pronounced to the point of becoming counterproductive and thus deleterious to the person’s ability to behave in an optimal fashion.
The fact that Dr. Piacentini and his colleagues seem to at least address the issue of anxiety within their therapy is, in my estimation, one more confirmation of my views. I wrote my story and reached my conclusions before I ever heard of him and his work or that practiced at the Duke University Medical Clinic. The fact that he and other professionals would independently arrive at at least some of the same conclusions that I have regarding remedial measures seems telling to me.
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In regard to your tics, I would advise you to try to reduce anxiety within your life as much as possible and perhaps take up various relaxation techniques such as breathing exercises and perhaps meditation. (I am not referring to religious meditation. Just practice keeping your mind as quiet and still as possible for progressively longer intervals.)

Once again, best of luck to you.
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Don S.
07-07-10, 10:49 AM
Ginnie:
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Thank you for your courteous response.

I wasn’t aware that ADHD is now officially classified as a “neurological disorder.” I thought it was classified as a “disruptive behavior disorder.” In any event, I would disagree with the “neurological” description of it the same as I do in the case of Tourette’s Syndrome. As to the latter description, what’s in a name?
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I view ADHD to be within the same pathological family as other disorders characterized by impulsiveness and obsessive tendencies.
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In regard to TS which you do not address (and upon which ADHD is so very often attendant), one problem I have with the “neurological disorder” description is that a significant percentage (I’ve read figures ranging from thirty to fifty percent) of youngsters with TS “outgrow” it upon reaching adulthood (which I believe is also the case with ADHD). If there is some physical anomaly within the central system that accounts for TS, then what accounts for this common remission upon reaching adulthood? Does the anomaly suddenly disappear of its own volition? If it remains, then what accounts for its seeming loss of the ability to cause the noted symptoms?
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To my mind, the fact that so many youngsters “outgrow” tics points to slowing metabolic processes and perhaps more mature intellectual abilities which better enable former youngsters with a history of tics to address and control the underlying psychological processes.

In regard to what you characterize as my “all or nothing” logic, tics are what not only constitutes TS but also define it. If a person is entirely tic free, then no one would ever even think of diagnosing him or her as having Tourette’s. Likewise, cancer is defined by the presence of malignant tumors: abnormal cell multiplication will (if not treated and cured) eventually destroy enough healthy tissue as to cause the death of the afflicted.<O:p< O:p< font> </O:p<>
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Unless one wishes to devolve into “New Age” thinking, I fail to see how any sort of talk therapy could possibly combat that which defines cancer: malignant, metastasizing tumors. Yet, behaviorial therapy has proven effective in treating that which defines TS.

Thanks again.

Don
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Logic
07-07-10, 05:41 PM
Logic:<o></o><o></o> In regard to your tics, I would advise you to try to reduce anxiety within your life as much as possible and perhaps take up various relaxation techniques such as breathing exercises and perhaps meditation. (I am not referring to religious meditation. Just practice keeping your mind as quiet and still as possible for progressively longer intervals.)<o></o>

I do try, I practice Zazen meditation (sitting) and Iaido (which I regard as moving zen) but is basically skilled control of a Japanese shinken/iaito blade.
I had a funny experience with zazen at a martial arts course one year, traditionally the zazen is at dawn and kept seperate from the rest of the practice which occurs later on in the day - anyway, there was a Monk leading the sesshin (not a spelling error). He noticed I was restless and took me aside, Miyamoto sensei I think his name was, but that's pretty irrelevant, I just remembered it!
He had a shinai with him (a bamboo training weapon) and after he had seated himself next to me, he would give me a rap with it if I moved too much, every time he gave me a smack he would say "restless mind...you must settle" and after seven days of getting hit with a stick, I was able to be at peace, and be still for the hour I was in that head-space with Miyamoto sitting next to me with a stick! Paradoxical some might say... Helped me. I just wish I could find a way that didn't involve the stick and getting struck with it...:rolleyes::)

Logic

Don S.
07-07-10, 07:48 PM
Logic
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We don’t want to veer too far off topic. However, I have been very interested in both Zen and Advaita Vedanta (what I consider to be Zen's close parallel within Hinduism) for some time. Although I am not a practitioner of either, I very much appreciate their philosophical undertones.<O:p></O:p>
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There is story concerning the Sixth Patriarch, which I first read in Zen Flesh, Zen Bones, that I found most illuminating. One day the patriarch happened upon two of his monks arguing about a flag blowing in the wind. One argued that it was the flag that was moving, while the other the wind. The patriarch settled the matter by counseling; “Mind is moving."

What I perceive to be the message here is very much an integral part of a philosophical proof of a creator that I wrote on my personal website and had published on an online article service. (It is based on Einstein’s STR.)

I often think that Parmenides and Zeno were right all along. If so, that’s more than a tad ironic for those who suffer from tic disorders!

Once again, best of luck to you in all aspects of your life!
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indolering
10-16-10, 01:46 AM
Don, where do you think behaviors come from?

Thoughts, feelings, behaviors all stem from the biological processes in your body...

Do you have tics, or are you a caretaker?

Don S.
10-22-10, 11:28 AM
Indolering,

In my opinion, the only way one can classify TS as an organic illness is to invoke the broadest sense of the concept, which is tantamount to saying that the cause of death is life. As I have said previously, if TS sufferers didn’t have bodies/brains then it is true that they wouldn’t suffer from tics, or anything else for that matter

I was diagnosed with TS while in the service. I have a website that deals with school bullying and TS, and I have written a short story that was published on an internet zine. It is entitled “Pride’s Prison” and is a thinly-veiled childhood memoir regarding school bullying as a result of a then undiagnosed relatively mild case of TS and a more severe case of what has been since formalized as ADHD.

My views are the product of both my readings and my inner reflections from an empirical perspective of living with the affliction. Although most of my childhood/young adult physical tics have now vanished (as is often the case in accordance with the affliction’s pathology), I still battle coprolalia (which began as a teenager) but rarely slip in public. There have been a few embarrassing incidents over the years.

If you are interested, I have written several articles on TS which explain my views and how I arrived at them. I would particularly commend to you the second and third ones at my website; the latter has been translated into Spanish and German as well. I am convinced that there are many professionals who deal with TS (especially psychologists and psychiatrists) who privately agree with my views but will not publicly come out and say so for political and economic reasons. This sentiment is based upon personal correspondence that I am not at liberty to discuss.

Classifying TS as an organic affliction has had decided economic benefits for many health care professionals. However, I fail to see how it has benefited us. Even if it had, truth must never be sacrificed on the altar of political/economic expediency, or at least that is how I feel.

Don

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K-Funk
05-18-11, 03:42 AM
I think it's safe to say that Don S. does not believe in neurobiological disorders whether ADHD, tourettes or otherwise. I think failing to recognize what most in the established medical community view as "the accepted view" of neurobiological diseases limits our ability to understand and treat these afflictions.

What say you ginnie?

It's probably pretty important to be careful about all or nothing thinking. Neurological disorders are not the same things as diseases so comparing tics to cancer is going to lead you astray because that analogy will break down so fast that it's pretty much not useful.

ADHD is a neurological disorder, there are things which help including Behavioural intervention therapy, because certain interventions help us doesn't erase the neurological issues and the same goes for other neurological conditions like tics. The brain is an extremely interesting organ and a very unique one.

Becoming aware of the urge prior and developing a substitute response does not allow for the conclusion that tics aren't neurological in origin. What it does mean is that when well rested and at the top of your game you can use a method that helps to control the physical expression. You might note that the 'urge' is not what is being targeted with the behavioural intervention therapy but rather the action that follows.

This was not touted as a cure but more an effective method of helping a person develop a coping strategy.

K-Funk
05-18-11, 10:49 AM
OK, so here's an article that seems to demonstrate how neurobiology and behavior intersect.

Contrary to intuition, people who suffer from the motor and vocal tics characteristic of Tourette syndrome actually perform behavioral tests of cognitive motor control more accurately and quickly than their typically developing peers do. According to evidence reported online on March 24 in Current Biology, a Cell Press publication, that enhanced control arises from structural and functional changes in the brain that likely come about from the need to constantly suppress tics.

http://www.sciencedaily.com/releases/2011/03/110324153016.htm

This would seem to indicate that neurobiology can be affected by external forces but doesn't necessarily eliminate biological origins/influence from the equation...

Don S.
05-21-11, 05:19 PM
K-Funk:
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Thank you for bringing this article to our attention. I have read it, and I have the same question regarding it as I have had with all the other studies that purport to prove that some physical anomaly within the central nervous system is responsible for TS. That question is: “Can this researcher diagnose TS from brain scans like the ones he used in his study? Can he identity on a blind basis a hundred people diagnosed with TS by observation from a series of two hundred MRI brain scans, the other hundred being brain scans (of the same area of the brain) of people with no history of tics, either as children or adults? If not, why not?”

This article doesn’t seem to indicate what area or areas of the brain Dr. Jackson had been scanning (or have I missed it?). Here is another article from your same source:

http://www.sciencedaily.com/releases/2009/05/090511210419.htm (http://www.sciencedaily.com/releases/2009/05/090511210419.htm)

Notice that in this study the researches claim support for their hypothesis that: “…alterations in frontostriatal circuitries underlie Tourette’s pathology.” They further conclude: “We suggest that Tourette’s is primarily caused by a dysfunction in prefrontal cortex areas rather than the basal ganglia, as had been previously thought.”

Well, perhaps this explains why TS couldn’t be diagnosed by brain scans from all those basal ganglia studies that have kept researchers gainfully employed for so long. Not to worry, though. Now they can move on to the brain anomaly hypothesis du jure.

Nevertheless, I do find the article you referenced to be of interest. Although the article is not the most clearly written one of this nature I’ve encountered, it seems to indicate that this researcher might be pointing to the possibility that structural changes within the brain might occur in reaction to an environmental stimulus rather than being an organic cause of TS from birth. I do find that interesting and it might yield useful insights into underlying physical processes resulting from repetition of behaviors and subsequent habituation.

(In regard to TS, the repeated behaviors that eventually become habit are attempted defense measures to chronic anxiety.)

It also at least attempts to take a stab at addressing stumbling blocks to the now (regretfully) orthodox theory that TS is organic in nature, ones I have pointed out myself in my essays on TS. They are: Why do TS cases range from mild to severe, and if TS is organic, why do so many children afflicted with it “outgrow” it upon reaching adulthood?<O:p></O:p>
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Simenora
05-21-11, 05:40 PM
Just as an observation, my son diagnosed TS, ADHD OCD, has always had complex verbal tics and oral tics but they become significantly pronounced with stress. I would tend to side with combined causation.

K-Funk
05-31-11, 05:11 PM
You, yourself have been dx with TS and ADHD correct? Did you ever take medicines for either before switching to behavior modification approaches?

K-Funk:
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Thank you for bringing this article to our attention. I have read it, and I have the same question regarding it as I have had with all the other studies that purport to prove that some physical anomaly within the central nervous system is responsible for TS. That question is: “Can this researcher diagnose TS from brain scans like the ones he used in his study? Can he identity on a blind basis a hundred people diagnosed with TS by observation from a series of two hundred MRI brain scans, the other hundred being brain scans (of the same area of the brain) of people with no history of tics, either as children or adults? If not, why not?”

This article doesn’t seem to indicate what area or areas of the brain Dr. Jackson had been scanning (or have I missed it?). Here is another article from your same source:

http://www.sciencedaily.com/releases/2009/05/090511210419.htm (http://www.sciencedaily.com/releases/2009/05/090511210419.htm)

Notice that in this study the researches claim support for their hypothesis that: “…alterations in frontostriatal circuitries underlie Tourette’s pathology.” They further conclude: “We suggest that Tourette’s is primarily caused by a dysfunction in prefrontal cortex areas rather than the basal ganglia, as had been previously thought.”

Well, perhaps this explains why TS couldn’t be diagnosed by brain scans from all those basal ganglia studies that have kept researchers gainfully employed for so long. Not to worry, though. Now they can move on to the brain anomaly hypothesis du jure.

Nevertheless, I do find the article you referenced to be of interest. Although the article is not the most clearly written one of this nature I’ve encountered, it seems to indicate that this researcher might be pointing to the possibility that structural changes within the brain might occur in reaction to an environmental stimulus rather than being an organic cause of TS from birth. I do find that interesting and it might yield useful insights into underlying physical processes resulting from repetition of behaviors and subsequent habituation.

(In regard to TS, the repeated behaviors that eventually become habit are attempted defense measures to chronic anxiety.)

It also at least attempts to take a stab at addressing stumbling blocks to the now (regretfully) orthodox theory that TS is organic in nature, ones I have pointed out myself in my essays on TS. They are: Why do TS cases range from mild to severe, and if TS is organic, why do so many children afflicted with it “outgrow” it upon reaching adulthood?<O:p></O:p>
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Don S.
06-02-11, 10:19 AM
You, yourself have been dx with TS and ADHD correct? Did you ever take medicines for either before switching to behavior modification approaches?

As stated previously, I was diagnosed with TS by a Navy psychiatrist and discharged because of it in the mid-seventies. (Fortunately, I had served more than enough time to qualify for full veteran status and accordant benefits.)

The diagnoses of Attention Deficit Disorder and Hyperactivity hadn’t been formulated as yet at that time. Subsequent to discharge, I never sought help from a mental health professional for TS per se, though I did for a relatively brief period of time for panic attacks at around age thirty. I took tranquilizes for that which helped both conditions to some extent. However, it was only when I discovered the works of Dr. Claire Weekes, an Australian physician, that my problem with acute anxiety was ultimately vanquished. (I have never had a reoccurrence.) <?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
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Dr. Weekes had been an early proponent of behavioral therapy in treating nervous illnesses, and after pondering her analysis of chronic and acute anxiety, I made the connection that all disorders once classified as “neurotic” were related and stemmed from the same source: chronic anxiety which causes what I term to be “acute self-awareness,” an evolutionary self-preservation process that has become counterproductive in regard to functioning in life at an optimal potential. <o:p></o:p>
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Although it is true that I have never been formally diagnosed with ADHD, I have no compunction in self-diagnosing such considering its high rate of comorbidity with TS and the self-acknowledged fact that as a kid I could have been the poster boy for ADHD. If you ever have an hour sometime, then perhaps you might read my free access short story "Pride’s Prison," which is a thinly-veiled personal memoir of my childhood problems. Perhaps many reading here could relate. <o:p></o:p>

Dizfriz
06-02-11, 11:03 AM
I very much suspect that Tourette's is like so many other disorders in the DSM in that they have an neurological basis or foundation but the expression is mitigated by a number of factors.

What I have found to be very consistent is that simple answers to complex questions are almost always wrong answers and either or responses very often fit into this category.

Nature is almost always complex and fuzzy around the edges. Simple answers seldom work very well.

Just my thoughts.

Dizfriz

Don S.
06-02-11, 11:37 AM
I very much suspect that Tourette's is like so many other disorders in the DSM in that they have an neurological basis or foundation but the expression is mitigated by a number of factors.

Dizfriz

Then I would suspect that you would appreciate the paper that K-Funk referenced and linked to on this thread concerning Dr. Jackson’s study. If I am understanding his conclusions correctly, he seems to be focusing on an adaptation to TS rather than a cause. His hypothesis appears to be that structural changes can occur within the brain in reaction to TS which serve to mitigate the affliction’s symptoms and perhaps account for its seemingly complete disappearance upon reaching adulthood in many cases. The adaptation is presumably more effective for some who suffer with TS than for others, thus the range in the severity of cases from mild to severe. (Perhaps behavioral therapies artificially induce such an adaptation as well.) <?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
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I find this hypothesis interesting and worth further investigation. Again, it doesn’t appear as if Dr. Jackson is pointing to a cause, but rather to an effect. Anyway, the article is worth reading if you haven’t already. <o:p></o:p>