Section 2: Treatment advances
Obsessive-Compulsive and Tic-Related Disorders

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Introduction

Obsessive-compulsive disorder (OCD) and tic disorders (TDs) affect many children and adolescents worldwide and are associated with substantial functional impairment in afflicted youth. Fortunately, in the last decade both conditions have been the focus of clinical research that has clarified key phenomenologic issues and provided empirical support for treatments including disorder-specific cognitive-behavioral interventions (eg, Refs1, 2, 3, 4, 5, 6). The co-occurrence of these disorders, which seems to be common, poses a particular challenge to clinicians with respect to making treatment recommendations to families and to implementing the chosen interventions.

This review provides information regarding the psychopathology of each of these conditions separately and when comorbid, as well as an outline of the empirically grounded and clinically informed approach to treatment of OCD and TDs. Moderator analyses of treatment response in the Pediatric OCD Treatment Study (POTS) I7 indicated that secondary, comorbid tic symptoms predicted poorer response to pharmacotherapy alone but not to cognitive behavior therapy (CBT) alone or to combined treatment in a trial in which OCD was classified as the primary disorder.8 However, the mediating variable that produced this result has yet to be fully uncovered. As yet, the converse (moderator analyses of the effect of OCD on treatment response in primary TDs) has not been explored in the context of a randomized treatment trial, and thus clinicians need to exercise their empirically informed judgment when considering treatment of primary TD when OCD is also present.

First the authors provide a focused review of psychopathology for each of these conditions, describe the core CBT protocols for treating each condition separately, and then take into consideration what is known about psychopathology and treatment when they are both present (see Table 1 for a comparison of OCD, tics, and OCD with comorbid tics). The authors' view is that there is much reason for optimism that children who have comorbid OCD and TDs can be successfully treated, but that treating clinicians have several factors to keep in mind as they attempt to do so. Reduction of core symptoms in both OCD and TDs is important in improving the quality of life for affected youth and their families, but the judgment of which of the two conditions is driving current functional impairment and which disorder influences the symptoms of the other one directly must guide the initial treatment plan.

Section snippets

Prevalence

OCD's prevalence rate in youth has been estimated at 1% to 3% (eg, Refs9, 10) with variability occurring perhaps as a result of research method variance.11 OCD is evident across development12 and is associated with substantial dysfunction and psychiatric comorbidity.13, 14 The National Comorbidity Survey Replication Study involving over 9000 adult participants in the United States estimated that the 12-month prevalence rate of OCD was 1.0%15; epidemiologic studies with children and adolescents

Prevalence

In a large community sample of 4475 youth, it was determined that .8% had chronic motor tics, .5% had chronic vocal tics, and .6% had Tourette syndrome (TS).44 Worldwide, TDs and TS are reported to affect 1% of youth.45 Notably, after the age of 20, fewer than 20% of individuals with TS continue to bear moderate to severe impairment,46 and 20% to 90% of individuals with TS reported experiencing at least slight to moderate impairment into their adult years.46, 47, 48 Unfortunately, efforts to

OCD and TIC Disorders: Phenomenologic Overlap, Distinctions, and Comorbidity

Although classified as separate disorders, the overlap between the symptoms of complex motor tic disorders and the compulsions associated with OCD is considerable, which makes the task of distinguishing the two phenomena challenging. Common clinical correlates that characterize these two disorders include typical childhood onset, a chronic waxing and waning course, and familial occurrence.79 TDs and OCD can also share similar clinical presentations including repetitive behaviors, intrusive

Implications for Clinical Practice With Comorbid OCD and TDs

Unfortunately, little has been done empirically to examine the treatment for comorbid OCD and TDs in children and adolescents. In their review of the literature, Ferrao and colleagues21 suggest that ERP alone is probably not as effective in treating TDs as it is for treating OCD, but that more research is needed; however, an adult study indicated that ERP was quite effective in treating TS and was actually more effective on some outcome measures than HRT.99 Other research concerning the

Implications for Research

There is much still to be determined regarding the optimal strategy or sequence of strategies for addressing comorbid OCD and TDs. The lack of empirical evidence on this topic currently hampers clinical decision-making with respect to providing empirically informed treatment recommendations for OCD and TDs in youth. Data from multiple clinical trials already support the efficacy of ERP and HRT, respectively, for these conditions, but more work is needed to determine whether a sequenced or a

Clinical Controversies

Perhaps the most interesting development in the field with implications for the treatment of OCD and disorders involving impulse control has to do with underlying assumptions related to the centrality of habituation. ERP and HRT theorists have consistently acknowledged the neurobiological nature of obsessions and premonitory urges that give rise to compulsions and tics, respectively. However, each treatment is predicated on the notion that, if the individual can refrain from acting on the urge,

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