OCD and Tourette Syndrome Re examining the Relationship By Charles S. At the outset of this article I would like to thank the hundreds of kids whom I have. Tourette's Disorder is diagnosed when multiple motor tics and one or more phonic . We refer to this syndrome as “Tourettic OCD” (TOCD) to underscore our view that 2. emphasize the nature of the functional relationship between subjective In addition he frequently had to re-touch objects until they “felt right” and had to. Tourette syndrome (TS) and obsessive-compulsive disorder (OCD) are model . In addition, it will be important to examine the possibility of age effects on the.
The course of the disorder can vary greatly from individual to individual, but in most cases OCD persists into adulthood though waxing and waning in severity.
Among the more common co-morbid conditions are depression, other anxiety disorders, eating disorders, and TS. Tic disorders typically begin in mid-childhood and peak during early adolescence, and like OCD, usually rise and fall in severity over the years.
By adulthood, tics tend to abate or be absent entirely. Prediction of the course of the disorder in any individual child is impossible. While the tics themselves can be problematic enough, many individuals with tics, and most people with TS, have features associated with a wide variety of other disorders. Among the more common features appearing in conjunction with tics are impulsivity, inattention, hyperactivity, and restlessness associated with ADHD; the behaviors and obsessive compulsive thoughts associated with OCD; the difficulties in learning associated with LDs; the emotional liability, irritability, anger, and aggression associated with mood disorders and oppositional defiant disorder; the fearfulness, avoidance, and clinginess associated with anxiety disorders; the guilt and helplessness associated with depression; and the sensory integration issues e.
The majority of children with TS have symptoms of one or more associated conditions. For OCD the psychological treatments of choice are the cognitive-behavior therapy CBT techniques of exposure and response prevention ERP and cognitive therapy CTwhile pharmacological treatment favors the serotonin reuptake inhibiting family of antidepressants, selective and non-selective SSRIs SRIsand a variety of augmenting medications.
The frequent concurrence of symptoms of both disorders in the same individual is one strong clue. Also, evidence from family studies and lines of genetic research suggest that the disorders are etiologically linked.
Even seasoned experts can be hard put to distinguish complex tics from compulsions. This can present a significant dilemma for clinicians attempting to make a differential diagnosis tic or compulsion? This is not a small point. Yet, there continue to be formal barriers to a clearly elucidated conceptual framework that would clarify the relationship between these disorders and that would provide pathways for practical solutions to frequently encountered clinical problems.
My colleagues at the Behavior Therapy Center of Greater Washington and I are convinced that our adoption of perspectives described here has greatly facilitated our understanding of the nature of the problems confronting our patients and our efforts to provide the most effective treatment possible.
My hope is that broader efforts to understand OCD and its variants, and to develop more effective methods to help sufferers and their families, might be enhanced by consideration of these views.
Tourettic OCD — Behavior Therapy Center of Greater Washington
It is my hope that others might similarly benefit if these ideas were more widely dispersed. Finally, I hope that the broader scientific effort to understand OCD in all of its manifestations may benefit from these insights drawn from clinical observation and practice. This symptom cluster is not uncommon, yet it is often peripheral to discussions of OCD and its treatment. Ascertaining a personal or family history of tics can be useful.
James Leckman and his colleagues at Yale.
Yet in clinical practice reliable information of that sort can be difficult to get. Moreover clinical decision-making in the treatment of such clients has yet to be clearly elucidated. Categorical thinking tic or compulsion? Unlike true OCD, in which cognitions obsessions lead to an emotional affective state and typically fear of the content of the obsession, TOCD sufferers report discomforting sensory experiences such as physical discomfort in body parts including hands, eyes, stomach, etc.
Unlike reports of subjective experiences associated with classic forms of OCD, individuals describe a relative absence of fear or concerns about catastrophic consequences occurring should the required actions not be performed. Instead, there are likely to be concerns that the discomfort might be intolerable or unending if the actions were left undone or done poorly. Sometimes, but not typically, symptoms include intrusive sexual aggressive or gruesome images.
The TOCD perspective opens the door to a broader range of treatment possibilities that drawn from an orthodox categorical perspective. Patients with TOCD are seen in our clinic with regularity. Patients utilizing these techniques are encouraged to suppress the unwanted responses for longer and longer intervals. On the medication side of the board, the highly knowledgeable medical professionals with whom we collaborate regularly are willing to augment SSRI medications with alpha-2 agonists, or with typical and atypical neuroleptics with greater confidence, even when the practice seems to cross the boundaries of standard diagnostic prescription.
They are methodical and judicious in their approach to the addition of other medications, particularly stimulants, because of their potential to initiate or exacerbate tics in some cases. By applying a broader range of therapeutic techniques to our TOCD patients, we have had increasing success in helping these individuals achieve greater degrees of mastery over their symptoms. I recommend that other clinicians adopt the TOCD perspective in efforts to help such patients.
Many of our patients come to us because OCD has been detected among a complex of other diagnoses. These children and their parents want to know how they developed so many things wrong with them. Questions about the appropriate diagnoses, the proper therapeutic approach esand the role of medication are foremost in their minds. A large proportion of these patients certainly not all — there are other routes to Alphabet Soup have hallmark features of TOCD along with the array of associated conditions that occur so often in conjunction with a nervous system that is prone to developing tics, but which may not manifest the kind of simple tics that are easiest to identify.
Previous visits to mental health professionals typically fostered the view that the child suffered from a seemingly unrelated cluster of disorders. At our clinic we view the situation differently; we see it as an array of problems resulting from a developing nervous system, from which clinical features emerge that cut across a range of diagnostic categories. This asynchrony can certainly present challenges for parents, teachers, family members, and peers. In such situations, it can be hard for the person to fulfil their work, family, or social roles.
In some cases, these behaviors can also cause adverse physical symptoms. For example, people who obsessively wash their hands with antibacterial soap and hot water can make their skin red and raw with dermatitis.
For example, a person compulsively checking the front door may argue that the time taken and stress caused by one more check of the front door is much less than the time and stress associated with being robbed, and thus checking is the better option. In practice, after that check, the person is still not sure and deems it is still better to perform one more check, and this reasoning can continue as long as necessary.
Good or fair insight is characterized by the acknowledgment that obsessive-compulsive beliefs are or may not be true. Poor insight is characterized by the belief that obsessive-complsive beliefs are probably true.
In such cases, the person with OCD will truly be uncertain whether the fears that cause them to perform their compulsions are irrational or not. After some discussion, it is possible to convince the individual that their fears may be unfounded. It may be more difficult to do ERP therapy on such people because they may be unwilling to cooperate, at least initially. There are severe cases in which the person has an unshakeable belief in the context of OCD that is difficult to differentiate from psychotic disorders.
Risk factors include a history of child abuse or other stress -inducing event. In cases where OCD develops during childhood, there is a much stronger familial link in the disorder than cases in which OCD develops later in adulthood. Examples would be moderate constant checking of hygiene, the hearth or the environment for enemies. Similarly, hoarding may have had evolutionary advantages.The OCD, ADHD, and Tic Disorder Triad
In this view OCD may be the extreme statistical "tail" of such behaviors, possibly due to a high amount of predisposing genes. Functional neuroimaging during symptom provocation has observed abnormal activity in the orbitofrontal cortexleft dorsolateral prefrontal cortexright premotor cortexleft superior temporal gyrusglobus pallidus externushippocampus and right uncus. Weaker foci of abnormal activity were found in the left caudateposterior cingulate cortex and superior parietal lobule.
Affective tasks were observed to relate to increased activation in the precuneus and posterior cingulate cortex PCCwhile decreased activation was found in the pallidum, ventral anterior thalamus and postetior caudate. Observed similarities include dysfunction of the anterior cingulate cortexand prefrontal cortexas well as shared deficits in executive functions. The first category of executive dysfunction is based on the observed structural and functional abnormalities in the dlPFC, striatum, and thalamus.
Symptom specific neuroimaging abnormalities include the hyperactivity of caudate and ACC in checking rituals, while finding increased activity of cortical and cerebellar regions in contamination related symptoms. This is supported by the observation that those with OCD demonstrate decreased activation of the ventral striatum when anticipating monetary reward, as well as increase functional connectivity between the VS and the OFC.
International OCD Foundation | OCD and Tourette Syndrome: Re-examining the Relationship
Furthermore, those with OCD demonstrate reduced performance in pavlovian fear extinction tasks, hyper responsiveness in the amygdala to fearful stimuli, and hypo-responsiveness in the amygdala when exposed to positively valanced stimuli.
Stimulation of the nucleus accumbens has also been observed to effectively alleviate both obsessions and compulsions, supporting the role of affective dysregulation in generating both. Studies of peripheral markers of serotonin, as well as challenges with proserotonergic compounds have yielded inconsistent results, including evidence pointing towards basal hyperactivity of serotonergic systems.
Despite inconsistencies in the types of abnormalities found, evidence points towards dysfunction of serotonergic systems in OCD. Although antipsychotics, which act by antagonizing dopamine receptors may improve some cases of OCD, they frequently exacerbate others. Antipsychotics, in the low doses used to treat OCD, may actually increased the release of dopamine in the prefrontal cortex, through inhibiting autoreceptors.
Further complicating things is the efficacy of amphetamines, decreased dopamine transporter activity observed in OCD,  and low levels of D2 binding in the striatum.
Findings such as increased cerebrospinal glutamate, less consistent abnormalities observed in neuroimaging studies, and the efficacy of some glutaminergic drugs such as riluzole have implicated glutamate in OCD. The Quick Reference to the edition of the DSM states that several features characterize clinically significant obsessions and compulsions. Such obsessions, the DSM says, are recurrent and persistent thoughts, impulses or images that are experienced as intrusive and that cause marked anxiety or distress.
These thoughts, impulses or images are of a degree or type that lies outside the normal range of worries about conventional problems. Compulsions become clinically significant when a person feels driven to perform them in response to an obsession, or according to rules that must be applied rigidly, and when the person consequently feels or causes significant distress. Therefore, while many people who do not suffer from OCD may perform actions often associated with OCD such as ordering items in a pantry by heightthe distinction with clinically significant OCD lies in the fact that the person who suffers from OCD must perform these actions, otherwise they will experience significant psychological distress.
These behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these activities are not logically or practically connected to the issue, or they are excessive. In addition, at some point during the course of the disorder, the individual must realize that their obsessions or compulsions are unreasonable or excessive.
Moreover, the obsessions or compulsions must be time-consuming taking up more than one hour per day or cause impairment in social, occupational or scholastic functioning.
With measurements like these, psychiatric consultation can be more appropriately determined because it has been standardized. OCD is egodystonicmeaning that the disorder is incompatible with the sufferer's self-concept.
OCPD, on the other hand, is egosyntonic —marked by the person's acceptance that the characteristics and behaviours displayed as a result are compatible with their self-imageor are otherwise appropriate, correct or reasonable. As a result, people with OCD are often aware that their behavior is not rational, are unhappy about their obsessions but nevertheless feel compelled by them.