Overview
Definition:
Tourette Syndrome (TS) is a neurodevelopmental disorder characterized by multiple motor tics and at least one vocal tic that have been present for more than a year
Obsessive-Compulsive Disorder (OCD) is an anxiety disorder characterized by unwanted, intrusive thoughts (obsessions) that lead to repetitive behaviors or mental acts (compulsions)
Comorbidity between TS and OCD is common, with studies indicating a significant overlap in genetic and neurobiological pathways.
Epidemiology:
The prevalence of TS is estimated to be around 1 in 160 children aged 5-17 years in the US
OCD affects approximately 1-3% of children and adolescents
The comorbidity rate between TS and OCD is high, with estimates ranging from 30% to 50% of individuals with TS also meeting criteria for OCD, and a substantial proportion of individuals with OCD having a history of tics.
Clinical Significance:
The co-occurrence of TS and OCD presents unique challenges in diagnosis and management
Untreated or inadequately treated comorbidity can lead to significant functional impairment, decreased quality of life, and increased risk of psychiatric complications
Effective therapy sequencing is crucial for optimizing outcomes and improving patient well-being.
Clinical Presentation
Symptoms:
Motor tics: sudden, rapid, recurrent, nonrhythmic movements
Simple motor tics include blinking, shrugging, grimacing
Complex motor tics involve purposeful-seeming movements like touching, jumping, or uttering specific words or phrases
Vocal tics: sudden, brief, repetitive sounds
Simple vocal tics include sniffing, throat clearing, grunting
Complex vocal tics include words or phrases, echolalia, or coprolalia (involuntary shouting of obscenities)
Obsessions: recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted
Common themes include contamination, symmetry, aggressive or horrific impulses, and forbidden thoughts
Compulsions: repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rigid rules
Examples include excessive washing, ordering, checking, counting, or mental rituals.
Signs:
Observed tics during physical or neurological examination
presence of repetitive, seemingly ritualistic behaviors
signs of anxiety or distress related to obsessions
impaired social functioning or academic performance due to tics and compulsions.
Diagnostic Criteria:
Diagnosis of TS is based on DSM-5 criteria: multiple motor tics and at least one vocal tic present simultaneously for more than 1 year, onset before age 18, not attributable to the physiological effects of a substance or another medical condition
Diagnosis of OCD is based on DSM-5 criteria: presence of obsessions, compulsions, or both
obsessions/compulsions are time-consuming or cause clinically significant distress or impairment
not attributable to the physiological effects of a substance or another medical condition
not better explained by another mental disorder.
Diagnostic Approach
History Taking:
Detailed history of tic onset, type, frequency, severity, and impact on daily functioning
Inquire about onset and nature of obsessions and compulsions, triggers, and associated distress
Screen for comorbid conditions like ADHD, anxiety disorders, depression
Family history of TS, OCD, or other neurodevelopmental/psychiatric disorders is important
Rule out medical causes of tics (e.g., post-infectious autoimmune disorders like PANDAS/PANS, metabolic disorders, drug-induced tics).
Physical Examination:
Complete neurological examination to rule out focal deficits or other neurological signs
General physical examination to assess for any underlying medical conditions
Observation for the presence and characteristics of tics and compulsions during the interview.
Investigations:
Generally, investigations are not required to diagnose TS or OCD
However, if a secondary cause for tics or OCD symptoms is suspected, further investigations may be warranted: Neuroimaging (MRI brain) to rule out structural lesions if focal neurological deficits are present
Blood tests (e.g., thyroid function tests, autoimmune markers if PANDAS/PANS is suspected)
Genetic testing is generally not indicated for routine diagnosis
Neuropsychological testing may be useful for assessing comorbid ADHD or learning disabilities.
Differential Diagnosis:
Other tic disorders (persistent motor tic disorder, persistent vocal tic disorder)
stereotyped movement disorders
chorea
myoclonus
paroxysmal dyskinesias
other anxiety disorders
schizophrenia (for delusions/hallucinations)
For OCD, consider generalized anxiety disorder, social anxiety disorder, hoarding disorder, trichotillomania, excoriation disorder.
Management
Initial Management:
Psychoeducation for the patient and family about TS and OCD, their chronic nature, and available treatments
Emphasize that tics can wax and wane and that OCD can be managed
A comprehensive assessment of functional impairment is essential to guide treatment intensity.
Medical Management:
For Tics: Alpha-adrenergic agonists (clonidine, guanfacine) are first-line options for mild to moderate tics
Dopamine receptor antagonists (haloperidol, risperidone, aripiprazole) are effective for severe tics but carry a risk of side effects
For OCD: Selective Serotonin Reuptake Inhibitors (SSRIs) are first-line pharmacotherapy
Common SSRIs used in children include fluoxetine, sertraline, fluvoxamine, and citalopram
Doses are typically higher for OCD than for depression
Clomipramine, a tricyclic antidepressant with SSRI activity, is also highly effective but may have more side effects.
Behavioral Therapy:
Comprehensive Behavioral Intervention for Tics (CBIT) is the first-line treatment for disruptive tics
It includes habit reversal training and awareness training
Exposure and Response Prevention (ERP) is the gold standard behavioral therapy for OCD
It involves gradually exposing the individual to their feared situations or thoughts (exposure) while preventing them from engaging in their compulsive behaviors (response prevention).
Therapy Sequencing And Integration:
The choice of initial therapy and sequencing depends on the severity and primary symptom burden
If tics are more prominent and significantly impairing, starting with CBIT or alpha-agonists may be considered
If OCD symptoms are more severe and causing significant distress or functional impairment, starting with ERP or an SSRI may be prioritized
Often, a combined approach is most effective
For example: 1
If both TS and OCD are severe: Begin with ERP for OCD and consider a low-dose SSRI for OCD symptoms
Concurrently, initiate CBIT for tics
If tics remain bothersome, consider an alpha-agonist
If OCD is refractory to SSRI or tics are extremely severe, augmentation with other agents or referral to specialized centers may be needed
2
If tics are the primary concern: Initiate CBIT
If OCD symptoms are mild or subclinical, monitor closely
If OCD emerges or worsens, introduce ERP and/or an SSRI
3
If OCD is the primary concern: Initiate ERP and/or an SSRI
If tics emerge or worsen, introduce CBIT and/or an alpha-agonist
Careful monitoring for medication side effects, particularly worsening tics with SSRIs or mood changes, is critical
The goal is to address both symptom clusters simultaneously or sequentially based on individual presentation and response.
Supportive Care:
Family counseling and support groups
Educational support (e.g., 504 plans in schools) to accommodate tics and compulsive behaviors
Regular follow-up with a multidisciplinary team including child psychiatrists, neurologists, therapists, and social workers.
Complications
Early Complications:
Social isolation, bullying, academic difficulties, self-injurious behaviors (e.g., head banging, nail biting), increased anxiety and depression, sleep disturbances.
Late Complications:
Chronic functional impairment, significant impact on vocational and social development, increased risk of substance abuse and personality disorders, persistent psychiatric comorbidities.
Prevention Strategies:
Early identification and intervention
Consistent and evidence-based treatment for both TS and OCD
Psychoeducation and skill-building for patients and families
School-based interventions and support
Addressing comorbid conditions promptly.
Prognosis
Factors Affecting Prognosis:
Severity and age of onset of TS and OCD
Presence and severity of comorbid conditions (ADHD, depression, anxiety)
Response to treatment
Family support and engagement
Access to specialized care.
Outcomes:
With appropriate and integrated therapy, many individuals can achieve significant reduction in tic severity and frequency, and substantial improvement in OCD symptoms, leading to improved functioning and quality of life
Symptoms may wax and wane over time
While complete remission may not always be achieved, effective management can lead to long-term stability.
Follow Up:
Regular monitoring by a qualified clinician is essential, especially during titration of medications and behavioral therapies
Follow-up frequency will vary based on treatment response and symptom stability, typically ranging from monthly to quarterly visits
Long-term follow-up is often necessary to manage fluctuating symptoms and address emerging issues.
Key Points
Exam Focus:
Remember that comorbid TS and OCD is common
Therapy sequencing is crucial: ERP/SSRI for OCD, CBIT for tics
Alpha-agonists are first-line for tics, SSRIs for OCD
Always consider PANDAS/PANS in the differential
Monitor for worsening tics with SSRIs.
Clinical Pearls:
Start behavioral interventions early
they are often as effective as or more effective than medications for milder symptoms
Integrate behavioral and pharmacological approaches for best outcomes
Always involve parents/caregivers in treatment planning and execution
Recognize that tic suppression can be exhausting and may increase anxiety.
Common Mistakes:
Treating only one condition while ignoring the other
Underestimating the severity of OCD in patients with TS
Prescribing SSRIs without adequate monitoring for tic exacerbation
Inadequate psychoeducation of families about the chronic and fluctuating nature of these disorders
Relying solely on pharmacotherapy without incorporating behavioral interventions.