Neil Hilborn and His Powerful "OCD" Poem
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. International OCD Foundation – OCD and Tourette Syndrome: Re-examining the Relationship. 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.
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.
TOURETTE SYNDROME AND OBSESSIVE-COMPULSIVE DISORDER
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. 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.
This difficulty may arise, in part, because the symptoms manifest in a subgroup of individuals i. 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.
TOCD patients are likely to benefit more from SSRI augmentation with low dose neuroleptics or alpha-2 agonists, neuroleptic monotherapy, or alpha-2 monotherapy than typical OCD patients. However, adjunctive treatment with alpha-2 agonists such as clonidine or guanfacine are less frequently considered, particularly in the absence of motor or phonic tics. Likewise, the addition of low-dose neuroleptics may not be considered in the absence of tics. Psychotherapeutic Interventions Clinicians working with TOCD patients likely will need to employ a modified approach to exposure and response prevention and incorporate adjunctive techniques to produce maximal treatment gains.
As such, the clinician and the patient must be prepared for a longer regimen of exposure and response prevention. With persistence, reductions in uncomfortable feelings and sensations will occur. Likewise, imagery techniques and diaphragmatic breathing may be used alone or in conjunction with exposure and response prevention.
A patient might for example practice stretching both arms away from an object he feels compelled to touch i.
Child and adolescent cases may require home visits to address specific issues. In our experience TOCD cases require greater measures of willingness to adopt an experimental posture within the therapeutic process. The nurturance of a truly collaborative relationship between therapists and even their youngest patients will maximize the chances of developing the right combination of therapeutic ingredients for successful treatment.
Finally, given the increased challenge of treating these patients, the treatment plan will often require augmentation with family therapy, school consultations, and supportive psychotherapy to address the peripheral problems so often associated with TOCD cases. Conclusion At this time, we would argue that there are practical benefits to be derived from the adoption of a clearly defined Tourettic OCD 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: What is the best way of identifying TOCD?
Will this conceptualization lead to more successful treatments? Is a new diagnostic category warranted? Further down the line, studies examining family history, personal history, course, treatment response and prognosis would be important in validating the TOCD construct.
References American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th ed. A method of eliminating nervous habits and tics.
Tic disorders and obsessive-compulsive disorder. Psychiatric Research, The Journal of Nervous and Mental Disease, British Journal of Psychiatry, American Journal of Psychiatry, Obsessive-compulsive disorder with and without a chronic tic disorder: Symptoms of obsessive-compulsive disorder. Contemporary issues in treatment pp. Examination of this hypothesis is outside the scope of the current analysis, requiring the inclusion of additional families, including bilineal families and those with offspring who are unaffected with TS.
TS had a somewhat lower heritability estimate than either OCD or ADHD; this is most likely an artifact caused by the decreased variation in the sample i.
Another is that OCD represents an alternative phenotypic expression of TS-susceptibility genes, a hypothesis that has been put forward in previous family studies Unfortunately we are unable in the current study to distinguish between these hypotheses, which could be best tested in multi-generational families.
TOURETTE SYNDROME AND OBSESSIVE-COMPULSIVE DISORDER
These results have potential relevance both for genetic studies of TS and related disorders and for clinicians. Another possibility would be to use individuals with one disorder as a replication sample for the other, for example, examining genetic variants associated with TS in a sample of OCD-affected individuals. For clinicians, our findings suggest that TS-affected families may need to be counseled that TS and OCD share genetic susceptibility factors, and thus that offspring of TS families may be at increased risk for either TS or OCD or for the combination of the two.
These findings also have implications for genetic studies, suggesting that the presence or absence of ADHD is not of direct relevance for genetic studies of TS and should not be considered either as an inclusion or exclusion factor for such studies.
However, these results are preliminary, and the complex relationship between these disorders requires further investigation to have clear clinical relevance. Thus, we cannot easily explain the strong environmental correlation and lack of genetic correlation between TS and ADHD.
It is possible that the observed association is related to specific environmental exposures such as prenatal maternal smoking that predispose an individual to both TS and ADHD, either alone or in combination with additional environmental or genetic environmental influences 53 We found some evidence to support this hypothesis in our TS families as well.
Such analyses, which are outside of the scope of this paper, are of particular interest in genetic epidemiological studies of complex traits such as TS, where the relationships between commonly co-occurring phenotypes are difficult to define.
Finally, and somewhat surprisingly, and in contrast to previous family studies, we did not find evidence for increased heritability of the less severe phenotypes of CMVT and OCB in combination with the more severe phenotypes of TS and OCD. This may be due to the fact that the sample consists of nuclear families rather than multigenerational pedigrees, where the co-segregation of these phenotypes has been more clearly established 11 There are some limitations to our study, most of which relate to the sample composition.
Because the sample consists of nuclear families ascertained for having at least two siblings with TS, generally excluding families who were bilineal for tics or OCD, there is little phenotypic variability with regard to tic diagnoses only 14 sibs were unaffected for TSand there are only a small number of families where both parents have either a tic disorder or OCD.
Additionally, although some information is provided by the few half-siblings, the vast majority of families in this study were biological full siblings.
Because we do not have diagnostic information on second and third degree family members, the heritability estimates are just that, estimates, as the VA component is not able to distinguish some genetic effects from environmental effects present within the family structure, potentially resulting in an over-estimate of the heritability if the shared environmental effects are substantial.
Similarly, the fact our sample was specifically ascertained for genetic studies rather than being a population-based sample may also affect the heritability estimates, in this case, leading to a potential under-estimate of the heritabilities.
In addition, we do not have data on putative environmental contributors to TS, OCD, and ADHD, which are ostensibly accounting for variance not explained by the genetic variance h2. Despite these limitations, the large sample size and the completeness of the clinical data make it possible to maximize the information available from such a sample in useful and previously unexplored ways. In summary, while comorbidities are often seen clinically and are the most common management currency for clinicians, they have not been consistently considered in phenomenology and etiology studies.
Taken together, our results extend the previously reported heritability analyses based on latent classes in TS families, now examining parent-offspring concordance for OCD and ADHD and genetic and environmental correlations between individual diagnoses While further research is clearly needed into the complex relationships, both genetic and environmental, between TS, OCD, and ADHD, for the present, our studies suggest that in genetic studies of TS, OCD could also be appropriately considered as a relevant phenotype, either as an alternate phenotype or as a more genetically homogenous subgroup within the TS phenotype while ADHD should not.
Mathews and Grados report no biomedical financial interests or potential conflicts of interest.