Tourette's and OCD

What is the meaning of ‘Obsessions’ in OCD?

Intrusive thoughts and rumination (leads to anxiety & discomfort)

What is the meaning of ‘Compulsions’ in OCD?

Repetitive behaviours that the individual feels driven to perform- usually to reduce stress caused by obsessions (e.g. obsession of contamination → compulsion of cleaning)

What are the types of obsessions found mostly in children and young people?

Magical or superstitious obsessions

What are the DSM-5 & ICD-11 criteria for OCD?

• Time consuming: 1hr+ a day

• Sig. distress/impairment in social, occupational or other important areas of functioning

• Not attributable to another medical or psychiatric condition or substance

What scale can be used for clinical interviews & questionnaires regarding OCD?

Yale-Brown Obsessive-Compulsive Scale

What is the lifetime prevalence for OCD?

1-4% with no sex differences and little geographical variation

When does the onset for OCD tend to be?

Late adolescence/young adulthood (peak age: 14.5)

What % of spontaneous remission is there in adult cases of OCD?

20-40%

What are some negative outcomes of OCD?

• Increased risk of early mortality and lower quality of life

• Psychiatric co-occurrences (e.g., anxiety, depression etc.)

• High risk of self-harm/suicidal ideation (50% of individuals with OCD)

• Dermatological complications (excessive hand-washing)

What impact does family history have on the likelihood of developing OCD?

Higher likelihood if first-degree relatives have OCD + monozygotic twins more at risk than dizygotic; genes not sufficient enough to explain onset

What are some environmental factors for OCD?

• Neuro-inflammation and infections

• Neurological insults (e.g. brain tumours)

• Trauma/stress

Describe the pathophysiology for OCD

Stimulus → Obsession + distress/anxiety kicks in → compulsions offer temporary relief from distress/anxiety which reinforces behaviour

What circuit is responsible for the motor/reward system?

Cortico-striato-thalamo-cortical circuit

What brain parts is the cortico-striato-thalamo-cortical circuit made up of?

• Orbitofrontal cortex

• Anterior Cingulate Cortex

• Basal Ganglia

• Thalamus

What are the pathways within the cortico-striato-thalamo-cortical circuit?

Serotonergic, dopaminergic and glutamatergic pathways

What are the most effective non-pharmacological interventions to help manage OCD?

CBT and ERP (exposure & response therapy)

What are the most effective pharmacological interventions to help manage OCD?

SSRIs and antipsychotics

What did Tao et al. (2022) find about interventions for OCD?

Combined intervention (CBT/ERP and SSRIs) is more effective than mono-therapy

What % of people with OCD do not respond to neither pharmacological or non-pharmacological interventions?

25-40%

What are tics?

Sudden rapid/brief, repetitive, non-rhythmic movements or vocalizations

How voluntary are tics?

Unawareness of tics in 30% of cases

What are tics generally preceded by?

A premonitory urge (e.g. an unpleasant bodily sensation, urge to move, impulse to tic, increased tension)

What are tics generally followed by?

A perceived relief and release of tension

What are some environmental influences of tics?

• Specific sensory stimuli

• Stress

• Excitement

• Tiredness

What are the three types of tic disorders?

• Transient tic disorder (Motor or vocal tics < 1 year onset < 18 years)

• Chronic motor/vocal tic disorder (Motor or vocal tics > 1 year onset < 18 years)

• Tourette’s syndrome (Multiple motor and at least one vocal tics > 1 year onset < 18 years

What are the prevalence rates for the three tic disorders?

• Transient tic disorder: 3%

• Chronic motor/vocal tic disorder: 1.6%

• Tourette’s syndrome: 0.3-0.9% with a 4:1 M/F ratio

What are the genetic factors around Tourette’s?

First degree relatives of patients with Tourette’s 10-100x more likely to show/have shown tics or tic-related conditions

What are some environmental factors related to Tourette’s?

• Maternal chronic anxiety

• Alcohol and cannabis use

• Post-infectious autoimmunity

• Neurological insults

What are some atypical neuro-cognitive & psychological patterns linked to Tourette’s?

• Link b/t atypical development of cortico-striatal networks involved in processing sensations and sensory stimulation

• Atypical activation of frontal-subcortical circuits (basal ganglia, insula & thalamus) in association with premonitory urges

What are some neuro-cognitive & psychological deficits linked to Tourette’s?

• Deficits in executive functions (inhibitory control and response inhibition) and social cognition (social reasoning, theory of mind, social decision-making)

• Deficits in motor skills and visuomotor integration, verbal fluency, planning, working memory, cognitive flexibility, attention, memory, symptoms or consequences

What are the co-occurring conditions of Tourette’s?

• ADHD (60%)

• Anxiety (40%)

• OCD (30%)

• Autism (20%)

What are some examples of psychiatric comorbidities found especially in Tourette’s + ADHD/OCD?

• Depression

• Anger & aggression control problems

• Sexually inappropriate behaviours

• Personality disorders

• Self-injurious behaviour

• Sleep problems

What are the main fundamentals for Comprehensive Behavioural Intervention for Tics (CBIT)?

• Habit reversal training: Tic-awareness & competing-response training

• Relaxation techniques

• Functional assessment: identification of personalised situational antecedents and consequences influencing tic severity

Explain the process of habit reversal training within CBIT

1) Create tic hierarchy (rank tics from most to least distressing)

2) Implement tic-awareness (focusing on premonitory urges + awareness of negative reinforcement cycle)

3) Implement competing response training (learn to initiate voluntary behaviour unrelated or opposite to tic

What did Yu et al.’s (2020) meta analysis on habit reversal training show?

Small to medium effect sizes for efficacy of habit reversal training + recommended CBIT as initial treatment option before initiation of pharmacotherapy or other interventions

What is the benefit of psychosocial interventions and support for dealing with Tourette’s?

Not effective in reducing symptoms but useful to support families/teachers with dealing with a child’s condition + helps reduce stigma surrounding Tourette’s

Which areas of intervention for Tourette’s need more research?

• Dietary & Physical interventions

• Neuro-cognitive interventions

What are the main similarities between OCD and Tic/Tourette’s?

• Genetic + environmental factors

• Pathophysiology

• Interventions

• Co-occurrences

What are the main differences between OCD and Tic/Tourette’s?

• Awareness/insight

• Anxiety (OCD) vs. Physical urges/tension (Tourette’s)

• Cognitive (OCD) vs. Motor (Tourette’s)

• Nature of obsessions/tics

• Functional role of compulsions/tics

• Age of Onset