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### Symptoms and comorbidity  Recent research has again demonstrated the wide prevalence of TS-associated comorbities. In addition, studies are clarifying to what extent comorbities may contribute to the types of tics that TS patients exhibit.  A retrospective review of 1,000,000 people in the Taiwan National Health Insurance Research Database examined the association between epilepsy with TS \cite{26597416}. 1062 children and adolescents with TS were matched on age and sex with a control group of 3186.The TS group had an 18-fold increased risk of epilepsy compared to the control group and even after adjusting for comorbidities (i.e., bipolar disorder, depression, learning difficulties, autism, anxiety disorder, sleep disorder), the risk of epilepsy was still 16-fold. Although the authors raise the issue that some tics may have been mistaken for seizures, they also suggest that TS children be followed closely for the development of epilepsy.  A study of 400 patients seen at a TS specialty clinic found that 39% had coprolalia and 20% had copropraxia \cite{26089672}. When the 222 patients with full comorbidity data were examined, only 13.5% had "pure" TS (i.e., without comorbidities). None of the "pure" TS group had coprolalia and none had a family history of obsessive-compulsive disorder. In contrast, 39% of the group with comorbidities exhibited coprolalia. These researchers also found that individuals with complex tics were significantly more likely to report premonitory urges than individuals with simple tics.   Emotional regulation difficulties were described in several three  studies reminding us that TS patients often report thatthe  tics are the least of their problems. An experienced clinician who has done research on "rage attacks" in TS has provided a clinically useful summary of current knowledge \citep{Budman_2015}. Greater In another study \cite{25716486} greater  irritability was seen in TS adults with more severe tics and those with comorbid ADHD \cite{25716486}. When 95 TS adults were compared with control subjects matched for sex, ADHD. \cite{26144583} found that  both men male  and women with female  TS subjects  had significantly higher scores for personal distress and gave themselves lower scores for rated  their abilities to take other people's perspectives \cite{26144583}. lower than the control subjects did.   In a large study of psychiatric comorbidity in TS, approximately 800 families were recruited primarily from TS specialty clinics in four different countries over a 16-year period \citep{25671412}. A total of 1374 participants with TS and 1142 family members unaffected by TS were included. 86% of the TS participants had at least one psychiatric comorbidity and 72% had either OCD or ADHD. Other disorders, involving mood, anxiety or disruptive behavior, each occurred in approximately 30% of the TS participants. The genetic correlations between TS and mood were accounted for by ADHD and OCD, while ADHD alone accounted for the genetic correlations of TS with anxiety and disruptive behavior disorders. See also \citep*{Prime:Hirschtritt:2015}.  More research is also being conducted on personality differences associated with TS. A small study of 17 male adolescents \cite{26078419} found that the only difference between the TS subjects and 51 age- and gender-matched controls on the Minnesota Multiphasic Personality Inventory-Adolescent was that the TS subjects scored significantly higher on the Obsessiveness Content Scale.  In an important, large contrast a  study of psychiatric comorbidity in TS, approximately 800 families were recruited primarily from 50  TS specialty clinics adults  in four different countries over Germany used  a 16-year period \citep{25671412}. A total variety  of 1374 participants with TS instruments to measure psychological symptoms  and 1142 family members unaffected by TS personality traits \cite{26112450}. Comorbidities  were included in the study. 86% of the TS participants had at least one psychiatric comorbidity common with 41% having OCD, 28% being depressed  and 72% had either OCD or 26% having  ADHD. Other disorders, involving mood, anxiety or disruptive behavior, each occurred in approximately 30% of the TS participants. The genetic correlations between TS Patients with OCD had more severe tics  and mood there  was accounted a trend  for by those with  ADHD to have more severe tics. Only 29% of the patients had no pathological personality traits. The demand-anxious trait was the most common personality trait (measured with the Inventory of Clinical Personality Accentuations) seen in patients  and OCD, was present in 39%  while ADHD alone accounted for the genetic correlations histrionic personality traits were not found in any  of TS these patients. Personality traits in patients  with anxiety "pure" TS were comparable to those of the control group. Interestingly, ADHD did not contribute to increased probability of pathological personality traits. Although quality of life was affected by both personality traits  and disruptive behavior disorders. See also \citep*{Prime:Hirschtritt:2015}. comorbidities, personality traits had a larger impact on quality of life.  A small study of 17 male adolescents \cite{26078419} found that the only difference between the TS subjects and 51 age- and gender-matched controls on the Minnesota Multiphasic Personality Inventory-Adolescent was that the TS subjects scored significantly higher on the Obsessiveness Content Scale. In contrast a study of 50 TS adults in Germany used a variety of instruments to measure psychological symptoms and personality traits \cite{26112450}. Comorbidities were common with 41% having OCD, 28% being depressed and 26% having ADHD. Patients with OCD had more severe tics and there was a trend for those with ADHD to have more severe tics. Only 29% of the patients had no pathological personality traits. The demand-anxious trait was the most common personality trait (measured with the Inventory of Clinical Personality Accentuations) seen in patients and was present in 39% while histrionic personality traits were not found in any of the subjects. For patients without comorbidities personality traits were comparable to what was seen in the control group. Interestingly, ADHD did not contribute to increased probability of pathological personality traits. Although quality of life was affected by both personality traits and comorbidities, personality traits had a larger impact on quality of life.  A retrospective review of 1,000,000 people in the Taiwan National Health Insurance Research Database examined the association between epilepsy with TS. 1062 children and adolescents with TS were \cite{26597416}. A group of 3186 without TS but matched on age and sex was used as a control group.The TS group had an 18-fold increased risk of epilepsy compared to the control group and even after adjusting for comorbidities (i.e., bipolar disorder, depression, learning difficulties, autism, anxiety disorder, sleep disorder), the risk of epilepsy was still 16-fold. Although the authors raise the issue that some tics may have been mistaken for seizures, they also suggest that TS children be followed closely for the development of epilepsy.  ### Course