Journal of Anxiety Disorders 25 (2011) 164–168 Contents lists available at ScienceDirect Journal of Anxiety Disorders The roles of anxiety and depression in connecting tic severity and functional impairment Adam B. Lewin a,∗ , Eric A. Storch a , Christine A. Conelea b , Douglas W. Woods b , Samuel H. Zinner c , Cathy L. Budman d , Lawrence D. Scahill e , Scott N. Compton f , John T. Walkup g , Tanya K. Murphy a a Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida College of Medicine, United States b Department of Psychology, University of Wisconsin-Milwaukee, United States c Center on Human Development and Disability, University of Washington, Seattle and Seattle Children’s Hospital, United States d Movement Disorders Program in Psychiatry, North Shore-Long Island Jewish Health System, Department of Psychiatry, New York University School of Medicine, United States e Yale Child Study Center, United States f Department of Psychiatry and Behavioral Sciences, Child & Family Studies, United States g Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, United States article info Article history: Received 13 July 2010 Received in revised form 25 August 2010 Accepted 27 August 2010 Key words: Tourette’s Disorders Chronic tic disorder Impairment Severity Anxiety Depression abstract The current study examined relationships between tic severity and both functional impairment and perceived quality of life (QOL) in adults with a chronic tic disorder. The authors explored whether these relationships were moderated by anxiety and depressive symptoms. Five-hundred adults with Tourette’s Disorder, Chronic Motor Tic Disorder, or Chronic Vocal Tic Disorder participated in a comprehensive self- report internet-based survey. Anxiety and depressive symptoms moderated the relationship between tic severity and functional impairment such that stronger relationships were documented in participants with elevated depressive or anxious symptoms. Limitations and implications for research and clinical practice are discussed. © 2010 Elsevier Ltd. All rights reserved. A diagnosis of a chronic tic disorder (CTD), including Tourette’s Disorder, requires the presence of tics for at least 12 months (APA, 2000). Tics are sudden, repetitive, and stereotyped movements (e.g., eye blinks, jerking motions, or muscle contractions) or vocal- izations (e.g., snorting, coughing) and vary in complexity, duration, intensity, and appearance. Tic onset typically occurs prior to adolescence (Bloch & Leckman, 2009). Chronic tic disorders have an estimated prevalence ranging 0.15–3% (Burd, Kerbeshian, Wikenheiser, & Fisher, 1986; Kadesjo & Gillberg, 2000; Mason, Banerjee, Eapen, Zeitlin, & Robertson, 1998). In approximately 33–65% of cases, chronic tics remit prior to adulthood (Bloch & Leckman, 2009; Leckman et al., 1998; Peterson, Pine, Cohen, & Brook, 2001) and 85% of cases show a reduction in tic severity (Bloch et al., 2006). Nevertheless, individuals whose symptoms persist beyond adolescence commonly report that tics negatively impact their functioning and quality of life (QOL). In a ∗ Corresponding author at: Department of Pediatrics, Rothman Center for Neu- ropsychiatry, University of South Florida College of Medicine, 800 Sixth Street South, Fourth Floor North, Box 7523, Saint Petersburg, FL 33701, United States. Tel.: +1 727 767 8230; fax: +1 727 767 7786. E-mail address: alewin@health.usf.edu (A.B. Lewin). sample of 90 adults, higher tic severity was associated with lower QOL and social functioning in adults (Elstner, Selai, Trimble, & Robertson, 2001), and, in one of the larger studies to date, 19% of 180 adults with CTD reported the presence of severe interfer- ence with familial, peer, and other social relationships (Altman, Staley, & Wener, 2009). Other research has found that adults with CTD have higher unemployment rates, decreased job satisfaction, lower income, diminished employment success, and lower QOL in comparison to individuals without a CTD (Bruun & Budman, 1992; Elstner et al., 2001; Meyers, 1988; Robertson, Trimble, & Lees, 1988; Shady, Broder, Staley, Furer, & Brezden-Papadopolos, 1995). Although estimates of tic-related impairment vary, data sug- gests that 88% of 99 individuals (ages 15–25) with tics to perceive functional interference (Erenberg, Cruse, & Rothner, 1987). Some CTD experts suggest that impact on functional impair- ment may be due to the presence of frequently co-occurring psychiatric conditions (e.g., depression, anxiety, or attention-deficit hyperactivity disorder [ADHD]) rather than to the tics themselves (e.g., Robertson, 2000). Depression (Comings & Comings, 1987; Müller-Vahl et al., 2010; Robertson, Channon, Baker, & Flynn, 1993; Robertson & Orth, 2006; Robertson & Stern, 1997) and anx- iety are commonplace among individuals with CTD. Estimates of depression in adults with CTD reach as high as 76% (Robertson, 0887-6185/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2010.08.016