Tic or Compulsion? It's Tourettic OCD

Based on experience with hundreds of adults, adolescents, and children with OCD treated at our clinic, we argue that a substantial number of OCD patients present for treatment with an identifiable variant of OCD—more precisely, an OCD and TD blend. This blend is distinguishable from purer manifestations of either disorder and can be identified exclusively by phenomenological presentation. These patients or their first-degree family members may or may not have met criteria for TD or another tic disorder and may or may not have classic OCD symptoms; yet it is our position that their presentation is phenomenologically akin to both TD and OCD. Moreover, we believe that these patients express a constellation of symptoms (i.e., a syndrome) that is categorically distinct from more familiar forms of OCD, although this syndrome may coexist with OCD symptoms in many individuals.

We refer to this syndrome as TOCD to underscore our view that these clinical manifestations are best understood and treated as a hybrid with features associated with the two disorders, as described in detail below. TOCD was chosen (a) to emphasize the fact that many of these patients exhibit symptoms closely resembling those found in the later developmental manifestations of TD in which OCD symptoms and complex tics are said to coexist (Bruun, 1988); (b) to deemphasize a personal or family history of tics, thus including individuals who never displayed clearly discernable motor or phonic tics; and (c) to promote this conceptual tool for the clinicians who are most likely to encounter patients with these characteristics, namely those working within the OCD realm. The TOCD term will help remind clinicians to address the Tourettic features of the clinical presentation. The new term also has the advantage of being clearly distinguishable from tic-related OCD and intentional repetitive behavior, terms that focus more on the presence and nature of particular behaviors rather than on broader pathological processes involved (i.e., repetitive behaviors of types commonly associated with OCD but driven largely by experiences of sensory discomfort typically associated with TD). Finally, the TOCD term may also promote greater interest in research on the OCD and TD interface, an arena that has had only minimal impact on standard clinical practice.

From the standpoint of clinical use, there are significant benefits to subsuming these characteristics into a single, well-defined syndrome based on clinical phenomenology. O'Sullivan et al. (2000) argue that phenomenological analysis of OCD spectrum disorders, including TD, can facilitate diagnostic formulations as well as treatment planning. In this spirit, the TOCD formulation as proposed here affords clinicians the opportunity to make a differential diagnostic determination based solely on presenting clinical characteristics. Accurate information regarding personal or family history, when available, bolsters diagnostic and clinical decision making, but in clinical practice, as in clinical research, these data are often difficult or impossible to ascertain (Swerdlow, Zinner, Robert, Seacrist, & Hartston, 1999). Thus, presence or absence of a personal or family history of TD or tics would not be required for assignment to the TOCD subgroup. When TOCD is identified, the clinical quandary indicated by the frequently asked question “Is it a tic or a compulsion?” can be resolved from the new perspective: “It is a blend of the two with characteristics associated with both.” More importantly, it will be argued here that such a determination will greatly enhance the likelihood that individuals who display TOCD can be more effectively treated.

As a heuristic device and conceptual framework, TOCD can do the following:

It has been our experience that individuals with TOCD present regularly to treatment, with a greater proportion of these being children and adolescents. Among adults the vast majority had childhood or adolescent onset of symptoms, but some developed their symptoms in early adulthood. They conform to many of the phenotypic distinctions reviewed by Leckman, McDougle, et al. (2000) in their description of tic-related OCD. TOCD patients often report a relative absence of elaborated obsessions and beliefs in catastrophic consequences, although they may report vague notions that something bad might happen if they do not perform compulsions. In addition, they frequently report explicit concerns that their discomfort will be intolerable and possibly unending if their compulsions are not performed. Compulsions themselves typically involve just-right or just-so requirements with an emphasis on symmetry, arrangement, positioning, evening up, ordering, touching, and numbers. A number of these elements (e.g., preoccupation with numbers) may be found among arrays of symptoms in purer forms of OCD. However, these tend to be relatively minor elements in larger and more elaborate obsessional systems in which anxiety derives from specified catastrophic consequences (e.g., washing hands a set number of times to protect against AIDS). In TOCD, compulsions reportedly are not associated with anxiety but with sensory phenomena such as localized physical tension, generalized somatic discomfort, and diffuse psychological distress (such as feelings of incompleteness). The performance of compulsions tends to serve the express purpose of reducing the focal, localized, or general discomfort as opposed to playing a more central role in the modulation of anxiety and prevention of catastrophic consequences. Elements of this formulation have been described by others such as O'Connor (2001) as cognitive tics, sensory-based rituals, sensory fulfillment, and Factor II as described by Leckman, Grice, et al. (1997).

Historical indicators for TOCD may include one or more of the following: early signs of sensory hypersensitivity (e.g., bothered excessively by clothing tags, scratchy fabrics, uneven shoe laces, confining clothes, etc.); a personal or family history of chronic or transient motor or phonic tics; multiple comorbid diagnoses including attention deficit disorder, learning disorders, and impulse control problems; a nonresponse or weak response to SSRI monotherapy; and a nonresponse, weak, or otherwise anomalous response to exposure (E) and response prevention (RP). Contrary to other reports (see George, Trimble, Ring, Sallee, & Robertson, 1993), we would not at this time include aggressive or sexual imagery as a defining feature of TOCD given our impression that the vast majority of TOCD individuals we have seen have not reported these symptoms.

The following three case studies illustrate several ways in which TOCD manifests itself. No individual symptoms are pathognomonic of TOCD; however, a distinguishable array of symptoms is identifiable in each case. These symptoms include

As these cases demonstrate, TOCD may manifest itself in the absence of a personal or family history of TD or chronic tic disorders (Case 1). Conversely, the TOCD syndrome may also present in the context of TD (Case 2). These patients may carry separate diagnoses of TD and OCD, although the phenomenological presentation of OCD symptoms conforms to the TOCD syndrome proposed here. Finally, Case 3 illustrates how the TOCD conceptualization can be applied to a subset of presenting OCD symptoms.

In each case, the question may arise as to whether the behaviors that relieve the tension are tics (simple or complex) or are technically compulsions. A growing body of research has begun to address this question by differentiating OCD-repetitive behaviors from Tourettic and tic-related behaviors (Cath, Spinhoven, Hoogduin, et al., 2001; George et al., 1993; Holzer et al., 1994; Miguel, Baer, et al., 1997; Miguel, Coffey, Baer, Savage, Rauch, & Jenike, 1995; Miguel, Rosario-Campos, et al., 2000). Collectively, these studies report more cognitive and affective phenomena associated with OCD as well as more contamination concerns and cleaning compulsions. OCD in the context of Tourette's or tics alone was associated more with sensory phenomena as well as more touching, tapping, and repeating behaviors. However, as Miguel, Coffey, et al. (1995) note, such discriminations do not distinguish between mutually exclusive diagnostic categories. Some individuals with OCD and Tourette's or tics will report contamination concerns and cleaning compulsions. Conversely, some individuals with OCD alone will report compulsions that involve repetitive touching, tapping, and repeating behavior with a relative absence of cognitive and affective components.

Arguably, the distinction between OCD-related phenomena and Tourette's-related phenomena is often too difficult if not impossible to make, even by clinicians well versed in this literature. This difficulty may arise, in part, because the symptoms manifested in a subgroup of individuals (i.e., those with TOCD) may in fact represent the same phenomenon. Cath, Spinhoven, Van Woerkom, et al. (2001) identify this possibility by noting that “the suggestion that the GTS [Gilles de la Tourette's Syndrome] plus OCD subjects constitute yet another subgroup distinct from GTS and from OCD can not be excluded” (p. 226). As such, conceptualization of these cases as a blend of both tics and compulsions may temporarily resolve the question of whether a particular behavior represents a tic or a compulsion. Viewed as a blend, the TOCD classification obviates the need to place patients in discrete TD or OCD diagnostic camps, thus limiting treatment options.

Many TOCD patients are at risk of being treated pharmacologically and psychotherapeutically as run-of-the-mill OCD patients. However, these patients are more difficult to treat and may be more susceptible to premature termination or to be labeled as treatment refractory. As such, these patients require special consideration, both pharmacologically and psychotherapeutically.

At this time, we would argue that there are practical benefits to be derived from the adoption of a clearly defined TOCD classification by clinicians. A significant number of patients who present with this atypical array of symptoms could be easily distinguished and identified. From that point, clinicians would be directed to potentially effective therapeutic components that otherwise might be overlooked in favor of standard OCD or TD treatments.

Questions may be raised as to how well this proposed formulation will stand up to scientific scrutiny. Information derived from research endeavors such as family genetic studies may suggest an appropriate diagnostic placement for individuals described here. Furthermore, the implications drawn here regarding neurological underpinnings, and effective therapeutic components, both pharmacological and behavioral, should be subjected to further empirical examination. Additional empirical research questions include whether the TOCD conceptualization will hold up as a heuristic: Is it valid? Can TOCD patients be distinguished reliably from TD and OCD? What is the best way of identifying TOCD? Will this conceptualization lead to more successful treatments? Is a new diagnostic category warranted?

Specific studies that will help determine the answers to these questions can begin with the development of an assessment device that includes items to discriminate features unique to TOCD from pure OCD and TD features. A large sample study should then be conducted to determine whether TOCD can reliably be discriminated from OCD and TD. Further down the line, studies examining family history, personal history, course, treatment response and prognosis would be important in validating the TOCD construct.