Prior research has been mixed on whether tic-related OCD is a clinically distinct subtype, with some studies showing differences in symptoms, treatment response, and comorbidities and others showing no differences.
It is also unclear if tic-related OCD responds differently to treatments like SSRIs and CBT.
This study aimed to clarify the clinical utility of a broad definition of tic-related OCD in a large sample of youth who were partial medication responders.
Conelea, C. A., Walther, M. R., Freeman, J. B., Garcia, A. M., Sapyta, J., Khanna, M., & Franklin, M. (2014). Tic-related obsessive-compulsive disorder (OCD): phenomenology and treatment outcome in the Pediatric OCD Treatment Study II. Journal of the American Academy of Child & Adolescent Psychiatry, 53(12), 1308-1316. https://doi.org/10.1001/jama.2011.1344
Key Points
- Tic-related OCD was very prevalent in the sample, occurring in over 50% of youth with OCD using a broad definition of tic status based on the presence of motor and/or vocal tics.
- Those with tic-related OCD did not differ significantly from those with non-tic-related OCD on demographic variables, OCD severity, comorbidities, or functioning.
- Some differences emerged in OCD symptom presentation, with fewer religious obsessions and washing/ordering compulsions in the tic-related OCD group.
- Youth with tic-related OCD responded equally well to all treatment conditions, including medication management alone and medication management plus CBT.
Rationale
Prior research examining whether tic-related OCD is a clinically distinct subtype has been mixed.
For example, some research has found that those with tic-related OCD are more likely to be male (Leckman et al., 1994), have an earlier age of OCD onset (Diniz et al., 2006), exhibit higher rates of aggressive obsessions and ordering/hoarding compulsions (Zohar et al., 1997; Hanna et al., 2002), and have increased levels of externalizing symptoms compared to those with OCD alone (Ivarsson, Melin, & Wallin, 2008).
However, other studies have found no significant differences in clinical characteristics like OCD symptom dimensions and severity, comorbidity rates, or overall functioning when comparing youth with tic disorders+OCD to those with OCD alone (Lewin et al., 2010).
Data on treatment response has also been inconsistent. One study found that the presence of tic disorders moderated outcomes, with no response to sertraline monotherapy but equal response to CBT alone or combined treatment (March et al., 2007).
Yet other studies have found no difference in CBT outcomes for those with chronic tics (Storch et al., 2008; Keeley et al., 2008).
Given these discrepant findings, it remains unclear if examining tic status dimensionally or using a broad conceptualization of “tic-related” OCD has utility for understanding the heterogeneity of OCD.
It also remains unclear whether youth with tic-related OCD respond differently to first-line treatments like selective SRIs and CBT. This study aimed to address these gaps by assessing the clinical utility of a broad tic-related OCD phenotype in a large sample of medication partial responders.
Method
- Secondary analysis of data from the Pediatric OCD Treatment Study II (POTS II), a 12-week randomized control trial comparing medication management to medication management plus CBT in 124 youth ages 7-17 with OCD.
- Tic status was defined as the presence of motor and/or vocal tics on the Yale Global Tic Severity Scale [YGTSS]
- Outcomes included demographic variables, OCD severity, comorbidities, functioning, and treatment response.
Sample
- 124 youth ages 7-17 with primary OCD diagnosis who were partial responders to an adequate SSRI trial.
- Recruited from specialty clinics at three sites.
Statistical Analysis
- Group comparisons using t-tests and chi-square tests
- Repeated measures ANOVA to examine change in OCD severity
Results
- 53% met broad criteria for tic-related OCD
- No differences in demographic variables
- No differences in OCD severity, comorbidities, or functioning
- Few OCD symptom differences
- Equal treatment response in all conditions
Insight
- A broad tic-related OCD phenotype is very common among youth with OCD, suggesting examining tic status dimensionally has utility.
- However, the presence of tics alone does not indicate a more severe or complex OCD presentation. Assumptions should not be made about OCD symptoms based on tic status.
- Youth with tics+OCD respond equally well to SSRI medication and the addition of CBT, indicating tic status should not guide OCD treatment selection.
Strengths
- Large well-characterized sample
- Use of gold standard measures (RCT)
- Inclusion of a wide range of comorbidity and functioning measures
- Examination of multiple treatment conditions
Limitations
- Sample limited to partial medication responders may limit generalizability
- Relied largely on parent report measures
- Did not examine neurobiological factors
Implications
The findings of this study support assessing for tic-related OCD dimensionally in clinical practice, rather than relying solely on categorical DSM diagnoses of chronic tic disorders. Given tic disorders often emerge earlier than OCD, a history of tics or subtle tics observed during evaluation may indicate shared underlying neural substrates.
Patterns observed here also suggest that simply observing tics during an intake likely does not indicate more severe, complex, or treatment-resistant OCD. Clinicians can feel more confident educating families that the presence of motor tics does not mean their child’s OCD will necessarily be harder to treat or require significant adaptation of first-line interventions like SSRIs and CBT.
However, the findings do not preclude the potential need for treatment considerations if tics are impairing in their own right or prove disruptive to ERP exercises.
However, accommodations like mindfulness skills to manage premonitory urges or botox for more severe tics could likely complement standard CBT.
Additional research is still needed on markers and mechanisms that may differentiate subgroups within the heterogeneous tic-related OCD population and predict who is most likely to have tic exacerbations during treatment.
For example, future studies could examine underlying neural substrates and neurotransmitter dysfunction, distinguishing simple transient tics from chronic and complex tics in the context of OCD. Identifying distinct endophenotypes could allow truly personalized intervention based on an individual’s tic profile.
Research building on existing neurobiological models highlighting the role of dysfunctional corticostriatal loops may prove particularly informative for ultimately matching specific symptom profiles to targeted treatments with the best empirical support.
References
Primary reference
Conelea, C. A., Walther, M. R., Freeman, J. B., Garcia, A. M., Sapyta, J., Khanna, M., & Franklin, M. (2014). Tic-related obsessive-compulsive disorder (OCD): phenomenology and treatment outcome in the Pediatric OCD Treatment Study II. Journal of the American Academy of Child & Adolescent Psychiatry, 53(12), 1308-1316. https://doi.org/10.1001/jama.2011.1344
Other references
Diniz, J. B., Rosario-Campos, M. C., Hounie, A. G., Curi, M., Shavitt, R. G., Lopes, A. C., & Miguel, E. C. (2006). Chronic tics and Tourette syndrome in patients with obsessive-compulsive disorder. Journal of Psychiatric Research, 40(6), 487–493. https://doi.org/10.1016/j.jpsychires.2005.09.006
Hanna, G. L., Piacentini, J., Cantwell, D. P., Fischer, D. J., Himle, J. A., & Van Etten, M. (2002). Obsessive-compulsive disorder with and without tics in a clinical sample of children and adolescents. Depression and Anxiety, 16(2), 59–63. https://doi.org/10.1002/da.10041
Ivarsson, T., Melin, K., & Wallin, L. (2008). Categorical and dimensional aspects of co-morbidity in obsessive-compulsive disorder (OCD). European Child & Adolescent Psychiatry, 17(1), 20–31. https://doi.org/10.1007/s00787-007-0631-z
Keeley, M. L., Storch, E. A., Merlo, L. J., & Geffken, G. R. (2008). Clinical predictors of response to cognitive-behavioral therapy for obsessive-compulsive disorder. Clinical Psychology Review, 28(1), 118–130. https://doi.org/10.1016/j.cpr.2007.04.003
Leckman, J. F., Grice, D. E., Barr, L. C., de Vries, A. L. C., Martin, C., Cohen, D. J., McDougle, C. J., Goodman, W. K., & Rasmussen, S. A. (1994). Tic-related vs. non-tic-related obsessive compulsive disorder. Anxiety, 1(5), 208–215. https://doi.org/10.1002/anxi.3070010504
Leckman, J. F., Riddle, M. A., Hardin, M. T., Ort, S. I., Swartz, K. L., Stevenson, J. O. H. N., & Cohen, D. J. (1989). The Yale Global Tic Severity Scale: initial testing of a clinician-rated scale of tic severity. Journal of the American Academy of Child & Adolescent Psychiatry, 28(4), 566-573.
Lewin, A. B., Chang, S., McCracken, J., McQueen, M., & Piacentini, J. (2010). Comparison of clinical features among youth with tic disorders, obsessive-compulsive disorder (OCD), and both conditions. Psychiatry Research, 178(2), 317–322. https://doi.org/10.1016/j.psychres.2009.10.022
Storch, E. A., Merlo, L. J., Larson, M. J., Geffken, G. R., Lehmkuhl, H. D., Jacob, M. L., Murphy, T. K., & Goodman, W. K. (2008). Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 47(5), 583–592. https://doi.org/10.1097/CHI.0b013e31816774b1
Zohar, A. H., Pauls, D. L., Ratzoni, G., Apter, A., Dycian, A., Binder, M., King, R., Leckman, J. F., Kron, S., & Cohen, D. J. (1997). Obsessive-compulsive disorder with and without tics in an epidemiological sample of adolescents. American Journal of Psychiatry, 154(2), 274–276. https://doi.org/10.1176/ajp.154.2.274
Keep Learning
- What theories might explain the high rate of tic co-occurrence in OCD? How might we test those theories?
- This study relied on parent report for tics and other clinical features. How might more objective measurement of tics and underlying neurobiology lead to different results?
- If youth with tic-related OCD respond equally to standard treatments, what adaptations to CBT or medication management may still be helpful to address or prevent worsening of tics?
