Psychopharmacotherapy of Obsessive-Compulsive Symptoms within the Framework of Tourette Syndrome

Abstract

While Behavioral Therapy (BT) should be recommended as the first step in the treatment of OCD as well as TS, medication can be added for augmentation and in certain situations (e.g. family preference, BT not available or feasible) the priority may even reverse. This narrative review is given on the complexity of drug treatment in patients comorbid for obsessive-compulsive disorder (OCD) and Tourette syndrome (TS) and other tic problems. OCD with TS is a co-occuring combination of two generally delimitable, but in detail also overlapping disorders which wax and wane with time but have different courses and necessities and options of treatment. Distinct subtypes like "tic-related OCD" are questionable. Obsessive-compulsive symptoms (OCS) and tics are frequently associated (OCS in TS up to 90%, tics in OCD up to 37%). Sensory-motor phenomena like urges and just-right feelings reflect some behavioral overlap. The main additional psychopathologies are attention-deficit hyperactivity disorder (ADHD), mood problems and anxiety. Also, hair pulling disorder and skin picking disorder are related to OCD with TS. Hence, the assessment and drug treatment of its many psychopathological problems needs high clinical experience, careful planning, and ongoing evaluation/adaptation. Drugs are able to reduce clinical symptoms but cannot cure the disorders, which should be treated in parallel in their own right; i.e. for OCD serotonin reuptake inhibitors (SSRI) and for TS (tics) certain antipsychotics can be successfully prescribed. In cases of OCD with tics, when OCS respond only partially, an augmentation with antipsychotics (recommended: aripiprazole and risperidone) may improve OCS as well as tics. Also, the benzamide sulpiride, an atypical antipsychotics, may be beneficial in treating the combination of OCS, tics and anxious-depressive problems. Probably, any additional psychopathologies of OCD might attenuate the effectiveness of SSRI on OCS; on the other hand, in cases of OCD with tics, SSRI may reduce not only OCS but also stress sensitivity and emotional problems and thus leading to better selfregulatory abilities, useful to improve tic suppression. In sum, some clinical guidance can be given, but there remain many uncertainties because of a scarce data base for psychopharmacotherapy in OCD with TS. Recently, a high quality primer on Tourette Syndrome (TS) has been published, giving a timely and comprehensive overview related to all relevant aspects of the disorder [1]. This includes the suggestion that primarily Behavior Therapy (BT) should be recommended for the treatment of both OCS/OCD and TS. BT seems to be equally effective for pure as well as tic-related OCD [2-4]. But many patients remain symptomatic after BT intervention. In this situation, medication comes into play for augmentation. Further, drug treatment may be given the priority if BT is not available, not feasible or not preferred by the family. Concerning the practically important relationship between obsessive-compulsive symptoms (OCS) and TS the present r...

Reduced axon caliber in the associative striatum of theSapap3knockout mouse

“…In addition, consistently with a large part of the clinical literature on OCD 14,15,17,18 , abnormalities in the corticostriatal associative circuits such as described for patients with OCD have also been described in this mouse model, with particular focus on the corticostriatal pathway between the lateral OCF and the associative striatum 59,60 However, a large part of the clinical literature pronounces the heterogeneity of OCD and an important comorbidity between tic-like and compulsive-like behaviors in both TS and OCD patients. Recently, Sapap3-KO mice have been found to additionally present tic-like movements such as simple head twitches and body jerks, behaviors, which are rescued with aripiprazole administration 31 ; these findings are consistent with yet another part of the clinical literature describing high comorbidity between OCD-and TS-like symptoms [19][20][21][22] . As such, in a mouse model that spans such a complex spectrum of tic-and compulsive-like RBs, we were surprised to find that axon caliber was affected only in the associative striatum, while the sensorimotor striatum was found unaltered.…”

“…The implication not only of the associative but also sensorimotor corticostriatal loops is further supported by the finding of synaptic alterations in both circuits in young adult Sapap3-KO mice: cingulate area 1/M2 cortical projections to the dorsomedial striatum (DMS), and primary motor/M2 cortical projections to the dorsolateral striatum (DLS) 32 . Indeed, the presence of a mixed nature of RBs and affected associative and sensorimotor circuits in the Sapap3-KO mice are in line with the clinical studies reporting comorbidity of tic-and compulsive-like symptoms in both OCD and TS patients [19][20][21][22] .…”

“…These cortico-striatal loops, which have been consistently described in connection with compulsive-like RBs, are referred to as the associative cortico-striatal loops [14][15][16][17][18] . Despite this putative anatomical segregation of different types of RBs, a great percentage of comorbidity has been reported between TS and OCD patients, which points towards the existence of a common anatomo-functional ground [19][20][21][22] .…”

The Psychometric Properties of Children’s Yale-Brown Obsessive-Compulsive Scale in Tic Disorders

“…Moreover, the genetic correlation between OCD and TD was higher than between OCD and ADHD [38]. Due to the close relationship between the OCS and TD, assessing OCS in patients with TD is an important issue in future studies [5].…”

“…TD's common comorbidity is Obsessive-compulsive disorder (OCD) [2,3]. The comorbid OCD in TS is up to 50% [4], and the obsessive-compulsive symptoms (OCS) is up to 90% [5]. The OCS in Tourette Syndrome (TS) are associated with poorer quality of life across the self, relationship, environment, and general domains [6].…”