coprolalia

Coprolalia encompasses the uncontrollable utterance of words and phrases that are culturally taboo or generally unsuitable for acceptable social use, when used out of context. The term is not used to describe contextual swearing. It is usually expressed out of social or emotional context, and may be spoken in a louder tone or different cadence or pitch than normal conversation. It can be a single word, or complex phrases. A person with coprolalia may repeat the word mentally rather than saying it out loud; these subvocalizations can be very distressing.Tourette Association of America. [https://tourette.org/resource/understanding-coprolalia/ Understanding Coprolalia – A misunderstood symptom]. Accessed 12 October 2021.

Coprolalia is an occasional characteristic of Tourette syndrome, although it is not required for a diagnosis of Tourette's. Typically, symptoms of coprolalia follow the development of phonic or motor tics by four to seven years. The severity of symptoms tends to peak during adolescence and subside during adulthood.  In Tourette syndrome, compulsive swearing can be uncontrollable and undesired by the person uttering the phrases. Involuntary outbursts, such as racial or ethnic slurs in the company of those most offended by such remarks, can be particularly embarrassing. The phrases uttered by a person with coprolalia do not necessarily reflect the thoughts or opinions of the person as they are unconsciously produced.{{Cite journal |last=Singer |first=Carlos |date=1997-05-01 |title=Coprolalia and Other Coprophenomena |journal=Neurologic Clinics |volume=15 |issue=2 |pages=299–308 |doi=10.1016/S0733-8619(05)70314-5 |pmid=9115463 |issn=0733-8619|doi-access=free }}

Cases of deaf Tourette patients swearing in sign language have been described.{{cite journal |vauthors=Morris HR, Thacker AJ, Newman PK, Lees AJ |title=Sign language tics in a prelingually deaf man |journal=Mov. Disord. |volume=15 |issue=2 |pages=318–20 |date=March 2000 |pmid=10752584 |doi=10.1002/1531-8257(200003)15:2<318::AID-MDS1018>3.0.CO;2-H|s2cid=7102229 }}{{cite journal |vauthors=Dalsgaard S, Damm D, Thomsen PH |title=Gilles de la Tourette syndrome in a child with congenital deafness |journal=Eur Child Adolesc Psychiatry |volume=10 |issue=4 |pages=256–9 |date=December 2001 |pmid=11794551 |doi=10.1007/s007870170015|s2cid=26254893 }}

It may occur after traumatic brain injury such as stroke and encephalitis;{{cite journal |vauthors=Dale RC, Webster R, Gill D |title=Contemporary encephalitis lethargica presenting with agitated catatonia, stereotypy, and dystonia-parkinsonism |journal=Mov. Disord. |volume=22 |issue=15 |pages=2281–4 |date=November 2007 |pmid=17914719 |doi=10.1002/mds.21664|s2cid=38995008 }} in other neurological conditions such as choreoacanthocytosis,{{cite journal |vauthors=Ruiz-Sandoval JL, García-Navarro V, Chiquete E |title=Choreoacanthocytosis in a Mexican family |journal=Arch. Neurol. |volume=64 |issue=11 |pages=1661–4 |date=November 2007 |pmid=17998451 |doi=10.1001/archneur.64.11.1661|display-authors=etal|doi-access=free |url= https://jamanetwork.com/journals/jamaneurology/fullarticle/794754 }} seizures,{{cite journal |vauthors=Caplan R, Comair Y, Shewmon DA, Jackson L, Chugani HT, Peacock WJ |title=Intractable seizures, compulsions, and coprolalia: a pediatric case study |journal=J Neuropsychiatry Clin Neurosci |volume=4 |issue=3 |pages=315–9 |year=1992 |pmid=1498584 |doi=10.1176/jnp.4.3.315}} and Lesch–Nyhan syndrome;Jinnah HA. [http://www.emedicine.com/neuro/topic630.htm Lesch-Nyhan Syndrome.] eMedicine.com (August 29, 2006). Accessed 28 October 2006. and rarely in persons with dementia or obsessive-compulsive disorder in the absence of tics.

The neural mechanisms underlying the presence of coprolalia alone are poorly understood. Current research is designed to locate the brain regions that are active during an involuntary tic. Individuals with Tourette Syndrome (TS) exhibit the symptoms of coprolalia, so researchers can study subjects with TS to deduce an etiology for phonic tics. Patterns of neural activity were tracked by using Positron Emission Tomography (PET) scans. The activity of the frontal operculum and Broca's area (Brodmann’s area 44 and 45), may be responsible for the initiation of these vocal tics. Both of these brain areas are responsible for planning and producing speech, which are active during coprolalic vocal tic episodes.{{Cite journal |last1=Stern |first1=Emily |last2=Silbersweig |first2=David A. |last3=Chee |first3=Kit-Yun |last4=Holmes |first4=Andrew |last5=Robertson |first5=Mary M. |last6=Trimble |first6=Michael |last7=Frith |first7=Christopher D. |last8=Frackowiak |first8=Richard S. J. |last9=Dolan |first9=Raymond J. |date=2000-08-01 |title=A Functional Neuroanatomy of Tics in Tourette Syndrome |url=http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/archpsyc.57.8.741 |journal=Archives of General Psychiatry |language=en |volume=57 |issue=8 |pages=741–748 |doi=10.1001/archpsyc.57.8.741 |pmid=10920461 |hdl=21.11116/0000-0001-A000-9 |s2cid=28185231 |issn=0003-990X|hdl-access=free}}

Limbic system structures such as the posterior cingulate cortex are also activated during coprolalic vocal tics. This region of the brain is responsible for emotional processing, so its increase in activation could reveal insights as to how taboo words may be organized differently than the neurolinguistic aspect of the brain.{{Cite web |title=Basal Ganglia: What It Is, Function & Anatomy |url=https://my.clevelandclinic.org/health/body/23962-basal-ganglia |access-date=2023-12-09 |publisher=Cleveland Clinic |language=en}}

Only about 10% of people with Tourette's exhibit coprolalia, but it tends to attract more attention than any other symptom.[https://web.archive.org/web/20050208082423/http://www.tsa-usa.org/what_is/Faqs.html Tourette Syndrome FAQ.] Tourette Syndrome Association. Accessed 6 October 2006.

There is a low number of epidemiological studies on Tourette syndrome due to ascertainment bias affecting clinical studies. Studies on people with Tourette's often "came from tertiary referral samples, the sickest of the sick".{{cite journal |author=Swerdlow NR |title=Tourette syndrome: current controversies and the battlefield landscape |journal=Curr Neurol Neurosci Rep |volume=5 |issue=5 |pages=329–31 |date=September 2005 |pmid=16131414 |doi=10.1007/s11910-005-0054-8|s2cid=26342334 }} Further, the criteria for Tourette's syndrome changed in 2000 when the impairment criterion was removed from the DSM-IV-TR for all tic disorders.{{cite web |url=http://www.psychnet-uk.com/x_new_site/DSM_IV/misc_pages/what_is_dsm_iv_tr.html |title=What is DSM-IV-TR? |author= |website=Psychnet-UK |access-date=21 June 2016 |quote=Tourette's Disorder and all of the Tic Disorders no longer require that symptoms cause distress or impair functioning.}} This resulted in an increase of diagnoses in milder cases. Additionally, many clinical studies suffer from small sample size. These factors combine to render older estimates of coprolalia occurrences outdated.

An international, multi-site database of 3,500 individuals with Tourette syndrome drawn from clinical samples found 14% of patients with Tourette's accompanied by comorbid conditions had coprolalia, while only 6% of those with uncomplicated ("pure") Tourette's had coprolalia. The same study found that the chance of having coprolalia increased linearly with the number of comorbid conditions: patients with four or five other conditions—in addition to tics—were four to six times more likely to have coprolalia than persons with only Tourette's.{{cite journal |vauthors=Freeman RD, Fast DK, Burd L, Kerbeshian J, Robertson MM, Sandor P |title=An international perspective on Tourette syndrome: selected findings from 3,500 individuals in 22 countries |journal=Dev Med Child Neurol |volume=42 |issue=7 |pages=436–47 |date=July 2000 |pmid=10972415 |doi=10.1017/S0012162200000839}}

One study of a general pediatric practice found an 8% rate of coprolalia in children with Tourette syndrome, while another study found 60% in a tertiary referral center (where typically more severe cases are referred).{{cite journal |author=Singer C |title=Tourette syndrome. Coprolalia and other coprophenomena |journal=Neurol Clin |volume=15 |issue=2 |pages=299–308 |date=May 1997 |pmid=9115463 |doi=10.1016/s0733-8619(05)70314-5|doi-access=free }} A more recent study in Brazil had 44 patients with Tourette syndrome, and found a 14% rate of coprolalia;{{cite journal |vauthors=Teive HA, Germiniani FM, Della Coletta MV, Werneck LC |title=Tics and Tourette syndrome: clinical evaluation of 44 cases |journal=Arq Neuropsiquiatr |volume=59 |issue=3–B |pages=725–8 |date=September 2001 |pmid=11593273 |doi=10.1590/S0004-282X2001000500014|doi-access=free}} a study in Costa Rica had 85 patients, and found that 20% had coprolalia;{{cite journal |vauthors=Mathews CA, Herrera Amighetti LD, Lowe TL, van de Wetering BJ, Freimer NB, Reus VI |title=Cultural influences on diagnosis and perception of Tourette syndrome in Costa Rica |journal=J Am Acad Child Adolesc Psychiatry |volume=40 |issue=4 |pages=456–63 |date=April 2001 |pmid=11314572 |doi=10.1097/00004583-200104000-00015}} a study in Chile had 70 patients, and found an 8.5% rate of coprolalia;{{cite journal |doi=10.4067/S0034-98871999001200010 |pmid=10835756 |title=Enfermedad de los tics (síndrome de Gilles de la Tourette): Características clínicas de 70 pacientes |trans-title=Tics disease (Gilles de la Tourette syndrome): clinical characteristics of 70 patients |language=es |journal=Revista Médica de Chile |volume=127 |issue=12 |pages=1480–6 |year=1999 |last1=Miranda C |first1=Marcelo |last2=Menéndez H |first2=Pedro |last3=David G |first3=Perla |last4=Troncoso Sch |first4=Mónica |last5=Hernández Ch |first5=Marta |last6=Chaná C |first6=Pedro |doi-access=free}} older studies in Japan reported a 4% incidence of coprolalia;{{cite journal |vauthors=Kano Y, Ohta M, Nagai Y |title=Tourette syndrome in Japan: a nationwide questionnaire survey of psychiatrists and pediatricians |journal=Psychiatry Clin. Neurosci. |volume=52 |issue=4 |pages=407–11 |date=August 1998 |pmid=9766689 |doi=10.1046/j.1440-1819.1998.00412.x|doi-access=free }} a 1996 clinical trial, conducted in Brazil, found that only 9 of 32 patients (28%) had coprolalia.{{cite journal |vauthors=Cardoso F, Veado CC, de Oliveira JT |title=A Brazilian cohort of patients with Tourette's syndrome |journal=J. Neurol. Neurosurg. Psychiatry |volume=60 |issue=2 |pages=209–12 |date=February 1996 |pmid=8708658 |pmc=1073809 |doi=10.1136/jnnp.60.2.209}} Considering the methodological issues affecting all of these reports, the consensus of the Tourette Syndrome Association is that the actual number is below 15 percent.

Specific treatment options for reliving motor and phonic tics (coprolalia) in Gilles de la Tourette syndrome include but are not limited to Botulinum toxin injections, antipsychotics or behavioral therapy depending on the individual's severity of symptoms.

Some patients have been treated by injecting botulinum toxin (botox) near the vocal cords. This does not prevent the vocalizations, but the partial paralysis that results helps to control the volume of any outbursts.{{cite journal |vauthors=Scott BL, Jankovic J, Donovan DT |title=Botulinum toxin injection into vocal cord in the treatment of malignant coprolalia associated with Tourette's syndrome |journal=Mov. Disord. |volume=11 |issue=4 |pages=431–3 |date=July 1996 |pmid=8813224 |doi=10.1002/mds.870110413|s2cid=10339547 }}{{cite journal |author=Jankovic J |title=Botulinum toxin in the treatment of dystonic tics |journal=Mov. Disord. |volume=9 |issue=3 |pages=347–9 |date=May 1994 |pmid=8041378 |doi=10.1002/mds.870090315|s2cid=19270507 }}{{cite journal |vauthors=Kwak CH, Hanna PA, Jankovic J |title=Botulinum toxin in the treatment of tics |journal=Arch. Neurol. |volume=57 |issue=8 |pages=1190–3 |date=August 2000 |pmid=10927800 |doi=10.1001/archneur.57.8.1190|doi-access=free}} Botox injections result in more generalized relief of tics than the vocal relief expected.{{cite journal |vauthors=Stern JS, Burza S, Robertson MM |title=Gilles de la Tourette's syndrome and its impact in the UK |journal=Postgrad Med J |volume=81 |issue=951 |pages=12–9 |date=January 2005 |pmid=15640424 |pmc=1743178 |doi=10.1136/pgmj.2004.023614}} Botulinum injections block neuromuscular transmission and decrease hyperactive muscle fibres thus reducing involuntary movement production.

Aripiprazole is an FDA-approved antipsychotic drug that "acts as an antagonist at the Dopamine receptor D2 under hyperdopaminergic conditions and displays agonist properties under hypodopaminergic conditions." D₂ receptors (striatal dopamine receptors) play an essential role in motor output and the initiation of movements. The overproduction of dopamine exacerbates the production of tics.{{Cite journal |last1=Augustin |first1=Shana M. |last2=Loewinger |first2=Gabriel C. |last3=O’Neal |first3=Timothy J. |last4=Kravitz |first4=Alexxai V. |last5=Lovinger |first5=David M. |date=2020-08-18 |title=Dopamine D2 receptor signaling on iMSNs is required for initiation and vigor of learned actions |url=http://dx.doi.org/10.1038/s41386-020-00799-1 |journal=Neuropsychopharmacology |volume=45 |issue=12 |pages=2087–2097 |doi=10.1038/s41386-020-00799-1 |pmid=32811899 |pmc=7547091 |issn=0893-133X}} Aripiprazole works as a selective dopamine regulator controlling the release of dopamine in the brain, reducing the production of tics.{{Cite journal |last1=Padala |first1=Prasad R. |last2=Qadri |first2=S. Faiz |last3=Madaan |first3=Vishal |date=2005 |title=Aripiprazole for the treatment of Tourette's disorder |journal=Primary Care Companion to the Journal of Clinical Psychiatry |volume=7 |issue=6 |pages=296–299 |doi=10.4088/pcc.v07n0605 |issn=1523-5998 |pmc=1324961 |pmid=16498492}} Recent studies provide support for aripiprazole for symptom management. Aripiprazole oral dosages were approved in 2012 for the management of tics in children and adults.{{Cite journal |last1=Sallee |first1=Floyd |last2=Kohegyi |first2=Eva |last3=Zhao |first3=Joan |last4=McQuade |first4=Robert |last5=Cox |first5=Kevin |last6=Sanchez |first6=Raymond |last7=van Beek |first7=Alet |last8=Nyilas |first8=Margaretta |last9=Carson |first9=William |last10=Kurlan |first10=Roger |date=November 2017 |title=Randomized, Double-Blind, Placebo-Controlled Trial Demonstrates the Efficacy and Safety of Oral Aripiprazole for the Treatment of Tourette's Disorder in Children and Adolescents |url=http://dx.doi.org/10.1089/cap.2016.0026 |journal=Journal of Child and Adolescent Psychopharmacology |volume=27 |issue=9 |pages=771–781 |doi=10.1089/cap.2016.0026 |pmid=28686474 |pmc=5689110 |issn=1044-5463}}

Habit reversal training is one of the most common CBI strategies used for patients with Tourettes syndrome. Patients work with a therapist to develop strategies to better anticipate the occurrence of potential tics and establish a designated response preventing the tics from occurring. Additionally, these therapies also support TS patients in implementing coping mechanisms following stress-inducing tics.

Coprolalia has also been documented in deaf individuals. Non-verbal phonic tics are referred to as "signing phonic tics" in deaf individuals. Coprolalia in signing individuals is characterized by uncontrollable fingerspelling of obscene and inappropriate words and phrases, the production of intercourse related signs, flicking middle fingers, or compulsive repetition of signs.{{Cite journal |last1=Robertson |first1=M. M. |last2=Roberts |first2=S. |last3=Pillai |first3=S. |last4=Eapen |first4=V. |date=2015-10-01 |title=Gilles de la Tourette syndrome in a cohort of deaf people |url=https://www.sciencedirect.com/science/article/pii/S1876201815001562 |journal=Asian Journal of Psychiatry |volume=17 |pages=65–70 |doi=10.1016/j.ajp.2015.06.017 |pmid=26216703 |issn=1876-2018}} TS is extremely understudied in the deaf community, often being misdiagnosed as schizophrenia. Researchers are still studying the relationship between deafness and Tourette's syndrome to combat misdiagnosis.{{Cite journal |last=Burd |first=Larry |date=2014-08-27 |title=Language and Speech in Tourette Syndrome: Phenotype and Phenomenology |journal=Current Developmental Disorders Reports |volume=1 |issue=4 |pages=229–235 |doi=10.1007/s40474-014-0027-1 |s2cid=143272775 |issn=2196-2987|doi-access=free }} 

The entertainment industry often depicts those with Tourette syndrome as being social misfits whose only tic is coprolalia, which has furthered stigmatization and the public's misunderstanding of those with Tourette's.{{cite journal|title= Tourette syndrome in film and television |vauthors= Calder-Sprackman S, Sutherland S, Doja A |journal= The Canadian Journal of Neurological Sciences |volume= 41 |issue= 2 |date= March 2014 |pages= 226–32|doi= 10.1017/S0317167100016620 |doi-access=free|pmid= 24534035 |s2cid= 39288755}}{{cite journal |title= Public perception of Tourette syndrome on YouTube |vauthors= Lim Fat MJ, Sell E, Barrowman N, Doja A | journal= Journal of Child Neurology |volume= 27 |issue= 8 |date= 2012 |pages= 1011–16|citeseerx = 10.1.1.997.9069|doi = 10.1177/0883073811432294|pmid = 22821136|s2cid= 21648806 }}{{cite news |author= Holtgren B |title= Truth about Tourette's not what you think |work=The Cincinnati Enquirer |date= January 11, 2006 |quote=As medical problems go, Tourette's is, except in the most severe cases, about the most minor imaginable thing to have. ... the freak-show image, unfortunately, still prevails overwhelmingly. The blame for the warped perceptions lies overwhelmingly with the video media—the Internet, movies and TV. If you search for 'Tourette' on Google or YouTube, you'll get a gazillion hits that almost invariably show the most outrageously extreme examples of motor and vocal tics. Television, with notable exceptions such as Oprah, has sensationalized Tourette's so badly, for so long, that it seems beyond hope that most people will ever know the more prosaic truth.}} The coprolalic symptoms of Tourette's are also fodder for radio and television talk shows.[https://web.archive.org/web/20011006192716/http://tsa-usa.org/drlaura.html Oprah and Dr. Laura – Conflicting Messages on Tourette Syndrome. Oprah Educates; Dr. Laura Fosters Myth of TS as "Cursing Disorder".] Tourette Syndrome Association (May 31, 2001). Accessed 6 October 2001.
* [http://www.tsa-usa.org/news/DrPhil.htm Letter of response to Dr. Phil.] {{webarchive |url=https://web.archive.org/web/20080831055605/http://www.tsa-usa.org/news/DrPhil.htm |date=August 31, 2008}} Tourette Syndrome Association. Accessed 8 May 2006.
* [http://tsa-usa.org/news/Garrison-Keillor.htm Letter of response to Garrison Keillor radio show.] Tourette Syndrome Association. Accessed 8 May 2006.

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