"Just Right" OCD

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Obsessive Compulsive Disorder (OCD) is a psychiatric disorder, which involves both obsessions (recurrent, persistent, intrusive thoughts, images, or urges that cause anxiety or distress) and compulsions (repetitive behaviors or mental acts that are aimed at neutralizing or reducing anxiety or distress or preventing the feared outcome.)  

Obsessions, thus, are unwanted private events, which typically result in not only anxiety regarding the persistence of the obsession itself but also a feared catastrophic outcome.

 Feared outcomes commonly involve anticipatory anxiety regarding themes such as being responsible for harm to oneself or to others, being defined as unethical or immoral, or imperfection. For example, obsessions regarding dirt and contamination may result in overwhelming fear that if the dirt and contamination are not mitigated, one may become ill or unintentionally cause others to become ill. This fear becomes so overwhelming that it drives compulsions to minimize the perceived potential for harm and decrease the distress. In the case of contamination, one might choose to engage in washing or cleaning compulsions to reduce the chances that illness will occur and drastically diminish the anxiety.

There is, however, a subtype of OCD, for which a feared outcome is not the driving force. This is often referred to as “just right OCD” or “touristic ocd (TOCD).” TOCD involves compulsions such as counting, symmetry/evening up, arranging, ordering, positioning, touching, and tapping.

  In TOCD, there is no elaborate obsessional belief structure or feared outcome, which drives these behaviors, but rather, intense somatic and/or psychological tension or discomfort, often described as something feeling incomplete or “not right.” Sometimes, the distress is heightened by a belief that unless the behavior is performed, the discomfort will be intolerable and/or infinite.

The behaviors are then carried out to relieve these uncomfortable sensations.

Some have postulated that this sensory-driven OCD is tic-like in nature and may be more distinctly characterized by an overlap between OCD and tic disorder/Tourette’s disorder (Mansueto & Keuler, 2005; Leckman et al, 1994).

Tics are sudden, rapid, repetitive, nonfunctional motor behaviors (motor tics) or vocalizations (phonic tics), which are often preceded by premonitory sensations. This buildup of tension is relieved by tic expression, much like scratching an itch. Common motor tics include behaviors such as eye blinking, shoulder shrugging, and head jerking, while common phonic tics include throat clearing, sniffing, and grunting.  Tics may also be complex in nature, involving a sequence of behaviors such as touching, gesturing, and repetition of words or phrases.  Tourette’s disorder (Tourette’s Syndrome [TS]) involves the presence of multiple motor tics and one or more phonic tic(s) during the course of the disorder.

Although once thought to be involuntary, individuals frequently have some control over the temporary suppression of these behaviors.

Tic disorders are not uncommon in individuals with OCD. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) sites a lifetime tic disorder prevalence rate of 30% in individuals with OCD. Moreover, a 2015 study of 1,374 individuals with TS found that 72.1% also met criteria for OCD or ADHD (Hischtritt et al., 2015). Also of note, individuals with OCD who have had a comorbid tic disorder differ phenomenologically in terms of their OCD symptom themes, comorbidity, course, and pattern of familial transmission, from those with no history of tic disorder (APA, 2013). Research has suggested a genetic relationship between OCD and TS as well as hypothesized a shared neurobiological underpinning. TOCD or “just right” OCD symptoms, thus, seem to be a possible intertwining of the two disorders.

From a clinical perspective, the distinction between OCD and tics can be challenging to determine. For example, repeated touching behavior may be viewed as tic behavior because of its brief, non-purposeful nature; however, this may be indistinguishable from OCD in that it may be seen as repetitive behavior carried out until it feels “right.” Such distinction, however, may be important for clinical decision-making.

Whereas the evidence-based treatments for OCD are the cognitive behavioral therapy - exposure and response prevention (ERP) and selective serotonin reuptake inhibitors (SSRIs), the evidence-based treatments for tic disorders are the cognitive behavioral therapy – habit reversal training (also known as, cognitive behavioral intervention for tics [CBIT]) and neuroleptic and alpha 2 agonists.  Thus, considering TOCD (which can be more challenging to treat than “classic” OCD) as a phenomenon existing in an overlap of these two disorders may not only draw attention to the need to comprehensively assess for all possible behaviors in the obsessive-compulsive spectrum but may also avail more treatment options.  Psychotherapeutically, these symptoms are typically treated with ERP as well as practice engaging in “just wrong” behavior, while added elements of HRT/CBIT, such as sensory-substitution strategies and diaphragmatic breathing are helpful in reducing localized tension. Pharmacologically, these individuals may be more likely to benefit from low-dose neuroleptic or alpha 2 agonist augmentation of SSRIs, than typical OCD presentations.  Thus, considering the intertwining of OCD and tics may better inform conceptualization and treatment.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5thed. Washington, DC: American Psychiatric Association; 2013:251-4.

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. and Rasmussen, S. A. (1994), Tic-related vs. non-tic-related obsessive compulsive disorder. Anxiety, 1: 208–215.

Mansueto, C.S. & Keuler, D.J. (2005). Tic or compulsion? Behavior Modification, 29(5): 784-799.

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