Tourette’s Syndrome also known as Gilles de la Tourette’s Syndrome is a neurodevelopmental disorder that typically begins in childhood or adolescence and is characterized by the presence of multiple movement tics and at least one vocal or phonic tic. A tic is a sudden, repetitive, non-rhythmic, intermittent and unpredictable motor movement or vocalization of sound that involves a discrete group of muscles.  A motor tic is a movement-based tic, whereas a phonic tic is an involuntary sound produced by the movement air through the nose, mouth, or throat.

Tics can also be classified as; Simple tics which are sudden, brief and repetitive tics involve a limited number of muscle groups, or Complex tics which are distinct, coordinated patterns of movements involve several muscle groups.

The number, frequency, severity, anatomical location, and complexity of tics varies with each person. Common examples of tics are blinking, coughing, throat clearing, sniffing, and facial movements. Some tics can also be invisible to an observer for example, tics such as tensing of the abdominal muscles or toe crunching.

Tics may increase with increasing stress, fatigue, anxiety, or illness, or when engaged in relaxing and passive activities like watching TV.
 

Tics may sometimes decrease when the personal is actively engrossed in or focused on a specific activity.  Tourette's syndrome is a more severe kind of tic disorder.

Examples of tics under various classifications:

Tics are typically preceded by a strong unwanted urge or sensation in the affected muscles which is known as “premonitory urge”. This sensation is similar to the urge to sneeze or scratch an itch. Sufferers of Tourette's syndrome  describe the urge to express tics as being a buildup of tension, pressure, or energy which they have a choice to release in order to relieve the sensation. The urge may cause distress in the part of the body associated with the resulting tic; and so following through with the tic is a response that relieves the sufferer of the uncomfortable urge.

Examples of this urge are the feeling of having something in one's throat when there may not be anything there at all, leading to a tic of clearing one's throat from time to time, or a feeling of discomfort in one's shoulders urging them to shrug their shoulders. The tic itself feels like a relief of the built up tension or urge, a similar feeling to scratching an itch or blinking repeatedly when one feels there is something on their eye in order to feel relief. Premonitory urges which precede tics are essentially what makes it possible to suppress an impendic tic.

The ability to suppress tics varies from person to person, and adults tend to have more of a grasp on it than children, who are often less aware of the premonitory urges in the first place. Doing so often however, results in tension or mental exhaustion. People with Tourette's tend to excuse themselves and find  a secluded or private place in order to release the suppressed urge, or in cases where they are unable to do so, they may experience a marked increase in the frequency of the tics after the period of suppression.

The exact cause of Tourette's is unknown, but it is well established that both genetic and environmental factors are involved. The exact mechanism that mediates the inherited vulnerability to Tourette's is also not well established, however tics are believed to result from dysfunction in cortical and subcortical regions of the brain. i.e. the thalamus, basal ganglia and frontal cortex.

There is no cure for Tourette's syndrome, neither is there a single most effective medication or therapy for it which effectively treats all symptoms. Treatment is focused on identifying the most troubling or incapacitating symptoms and helping the individual to manage them. Education, reassurance and psychobehavioral therapy are often sufficient for the majority of cases.

Specific symptom management may include behavioral, psychological and pharmacological therapies, although the pharmacological treatment is often reserved for more severe symptoms.

Transvestic disorder is a condition characterized by the experience of recurrent, intense sexual arousal derived from cross-dressing, or dressing as a member of the opposite gender, with the urge to do so causing significant levels of distress or impairment of the individual’s daily life.

Someone with transvestic disorder may be predisposed to developing depression, feelings of guilt, and or shame due to the bizarre nature of the urges they feel to cross-dress. These feelings often come about as a result of feelings of disdain or outright disapproval from their family, friends, partner, or anyone in their circle of influence, or even their own feelings of what the repercussions of their crossdressing may be.

Most people who experience transvestic disorder are heterosexual men, and the most common reason they seek treatment for transvestic disorder is because it interferes with their romantic relationships, or marriages with women, and can also affect their relationships with family and coworkers etc.

Symptoms of Transvestic Disorder

The symptoms of transvestic disorder are predominantly strong feelings of shame, guilt, and anxiety associated with the act of cross-dressing. Cross-dressing ranges in severity, from wearing only one single article of clothing that is typically associated with the opposite sex, to an entire outfit complete with shoes, accessories, hair and full makeup.

In order to be officially diagnosed with transvestic disorder, according to the DSM-5, a person must report to have experienced persistent and intense levels of sexual arousal from the act of fantasizing about, or actually acting upon the urge to wear one or more pieces of clothing normally worn and associate with the opposite sex. These said fantasies or compulsions must have gone on for at least six months and must have caused extreme levels of distress to the individual, or caused dire dysfunction in their social, professional, or romantic areas of interaction. The urges to cross-dress, may be continuous and unrelenting or intermittent and fluctuating in nature.

Sufferers may also become stuck in a negative behavioral cycle of buying clothing purposefully for cross-dressing, wearing it during a bout of cross-dressing, and ending up throwing it away with feelings of shame, in hopes of quitting. As such they may run into some financial difficulty, or may end up being diagnosed with comorbidities such as fetishism, where they are sexually aroused by the feeling of different fabrics, materials, or types of garments; or masochism, where they experience sexual gratification or satisfaction from their own pain or humiliation.

Symptoms of Transvestic Disorder

There has not been a specific cause outlined for transvestic disorder. It has however been observed that sometimes in childhood, the act of cross-dressing sometimes causes excitement which may, after puberty, become sexual excitement, and as the person ages through adulthood and the behavior is repeated and reinforced, the desire to cross-dress may become stronger.

Treatment of Transvestic Disorder

It is important to note that, cross-dressing in itself is not a disorder, and so it does not require treatment. However individuals diagnosed with transvestic disorder typically require psychotherapy in order to understand their urges, to navigate through the pressures society places on them, and to work on lessening the symptoms of shame and guilt. A person with a history of transvestic disorder is considered to be in remission when their desire to cross-dress has not caused them distress or disrupted their daily life or interpersonal relationships in at least five years.

Trichotillomania is a condition characterized by a compulsive and unexplained urge to pull out one’s own hair. The pulling of hair can be from any part of the body at all, however it is most often seen to affect areas such the scalp, the eyebrows, eyelashes, and sometimes, the pubic region. The severity of the hair-pulling ranges from mild to severe.

Trichotillomania is classified as one of a set of behaviors collectively known as body-focused repetitive behaviors (BFRBs).  These are a set of behaviors involving compulsively damaging one's physical appearance or causing physical injury to oneself, such as hair-pulling, picking, biting, or scraping one's hair, skin, or nails. Trichotillomania refers to the act of compulsive hair pulling, while dermatillomania and onychophagia refer to compulsive skin picking, and compulsive nail-biting respectively.

Trichotillomania often has its onset coinciding with the onset of puberty in many persons diagnosed with the disease.  The first symptoms would typically appear between ages 10 and 14. This does not however exempt infants, younger children, older teens or adults. In general, it often occurs together with other psychological problems, such as anxiety, OCD, body dysmorphia, substance abuse, or eating, mood, and personality disorders.

Symptoms of Trichotillomania

• A compelling urge to pull one's own hair out from the scalp, eyebrows, eyelashes, pubic area, legs, chest, or elsewhere on the body.
• Having attempted multiple times to stop or decrease the act of hair pulling but proving futile.
• A significant amount of distress due to the hair-pulling, causing decline in the individual’s social, academic, occupational, or interpersonal functioning.
• The behavior is compulsive and can tend to occur without the individual being conscious of it happening.
• It results in a significant degree of hair loss that can lead to alopecia or bald spots. However in order for bald spots to warrant a diagnosis of Trichotillomania, all other medical causes of alopecia must be ruled out.
• The behavior must also not have the capacity to be attributed to any other mental health disorder; for example an individual with a body dysmorphic disorder, can result in pulling out their hair in order to correct a perceived “imperfection,” and not due to a compulsive need to pull.

Effects of Trichotillomania

1. The distress associated with the disorder can be severe to the extent of predisposing or leading 
     one to: 

• Feelings of shame, anxiety, depression, or embarrassment related to the condition which may be perceived by others as bizarre.
• Avoiding developing any close relationships, romantic or otherwise.
• Refraining from attending social events or getting a haircut
• Using scarves, wigs, alternative hairstyles, or makeup to cover up areas of the body with the signs of hair loss

2. Trichotillomania can cause damage to skin tissue and in the long run lead to infections, especially if
     foreign bodies such as tweezers, scissors, or other sharp objects are used to help in the hair
     pulling.

3. In some cases, the individual will engage in “rituals” after pulling the hair out, such as rolling the
    hair between their fingers, putting the hair on their lips or face, or inspecting the hairs. Others will
    also go to the extent of chewing or ingesting the pulled hairs, and that is another condition on its
    own, known as trichophagia. Trichophagia has the potential to be fatal, as it can result in the
    development of hairballs that can lead to obstruction of the bowel.

Causes of Trichotillomania

The exact cause of trichotillomania is not fully understood, though experts suggest that, as with other mental health disorders, a mixture of genetic as well as environmental causes are most likely the cause.

The disorder can also be used as a means of avoiding stressful events or releasing tension that builds up as a result of overwhelming emotions such as impatience, frustration, dissatisfaction, or boredom.

Treatment of Trichotillomania

The shame and guilt attached to the condition often prevents many persons from willingly seeking treatment. Also, because the disorder is not very widely understood, a lot of people struggling with it are more often than not, unaware of the fact that it is a full blown mental health condition for which they can seek help. Examples of treatment modalities used are; Cognitive behavioral therapy and habit reversal training. Support groups can also be helpful and are mainly internet based.as it targets the thoughts, emotions, and habit cycles that lead to pulling behaviors. Other kinds of therapy such as ACT and dialectical behavioral therapy (DBT) have also shown promise, especially when combined with HRT. Currently, no specific medications have been approved for the treatment of trichotillomania.

Trauma is referred to as the emotional response of an individual to a distressing experience or occurrence. It is almost unusual for one to go through life without encountering some form of trauma at all.

Traumatic events are usually quite unexpected and sudden in onset, tend to take unpredictable turns, most often involve a serious threat to one's life or wellbeing, and feel beyond a person’s span of control. Most traumatic events are able to cause a person to feel a sense of insecurity or to have an impending sense of doom, in the sense that anything catastrophic could happen at any time without warning.

Common examples of traumatic events include; loss of a loved one, breakup of a long-term relationship, road traffic accident, cancer diagnosis, being a victim of domestic violence or rape, military war veteran experiences, and loss of property etc.

Types of Trauma

Acute trauma refers to the intense feelings of distress experienced in the immediate aftermath of a one-time event and the reaction to it is short in duration. For example the sudden death of a loved one, being involved in a vehicular accident, or being a victim of physical or sexual assault.

Chronic trauma comes about as a result of harmful events that are repeated more than the initial occurrence, or tend to go on for a prolonged period of time. For example trauma developed in response to being in an abusive marriage, being neglected as a child, being a victim of domestic violence, or long-term sexual abuse or being bullied persistently.

Complex trauma results from having to experience multiple, repeating traumatic events from which one cannot see a possibility of escape, and feels trapped. It causes a feeling of insecurity and leads to hypervigilance, constant and obsessive monitoring of one's environment and constantly looking out for possible threats.

Adverse Childhood Experiences are a wide range of unfortunate situations that children are exposed to or made to witness while growing up, before they have the capacity to develop effective coping skills. They disrupt the normal course of development of a child's mind and the extent of the emotional injury can last long into adulthood and cause problems for the individual long after the occurrence of the event. Being physically or sexually abused, losing a parent or a close family member or a pet, and divorce of parents, having emotionally abusive parents are some of the most common types of Adverse Childhood Experiences.

Secondary or vicarious trauma is one that arises from ones exposure to another person’s suffering. It more often than not strikes people in professions that are first responders to cases of injury and accidents, such as physicians, nurses, paramedics, fire fighters, police etc. After prolonged exposure to such trauma, many such individuals develop compassion fatigue and avoid being emotionally involved in other people’s trauma in order to protect themselves from experiencing distress also.

Efffects of Trauma

Being exposed to troubling events activates the amygdala, which is a structure in the brain responsible for detecting threats, and that sends out alarms to various systems in the body to go into defense mode. The sympathetic nervous system then jumps into action, causing the release of adrenaline and noradrenaline and stress hormones that prepare the body for a fight or flight response.

Fear, anxiety, shock, and anger, aggression, and mutism are all normal responses to trauma. These negative feelings subside as time goes on and the experience begins to fade from memory, but for some people, the distressing feelings can linger on for extended periods of time and end up interfering with their day to day functionality.

Persons who have suffered long-term trauma go on to develop emotional disturbances, such as anxiety, anger, sadness, survivor’s guilt, disassociation, anhedonia which is the inability to find pleasure in things that were previously pleasurable, or PTSD (post-traumatic stress disorder). Such persons are constantly living in defense mode, and become hyper vigilant to the possibility of any threats or dangers, they may experience trouble sleeping, nightmares, flashbacks, and difficulties with day to day survival.

Some people can also experience the exact opposite, and undergo a period of post-traumatic growth, where they end up building stronger relationships, redefining their relationship with themselves, finding greater purpose and gaining a deeper appreciation for life itself.  As contradictory as it sounds, post-traumatic growth can also exist, especially following a near death experience.

Treatment for Trauma

If trauma is not treated, it can end up wreaking havoc on one's personal and professional life. There are various modalities of treatment with the aim of alleviating trauma.

• Lifestyle changes such as eating healthy, exercising, avoiding alcohol and drugs, getting enough sleep, seeing loved ones and interacting with community such as church family etc. and prioritizing self-care.
• Psychotherapy helps to build resilience, develop coping mechanisms, and address any unresolved feelings that are keeping one from overcoming their trauma.
• Exposure therapy and cognitive reappraisal therapy specific and reliable treatments for trauma and PTSD.
• Medications can be used in extreme cases.
• Participation in support groups and engaging with communities of people with similar experiences as well as survivors, have also helped in many situations of trauma.