رفتارهای تکراری در سندرم تورت و وسواس با و بدون تیک: تفاوت ها چیست؟

Gilles de la Tourette Syndrome (GTS) and obsessive–compulsive disorder (OCD) share obsessive–compulsive phenomena. The aims of this study were to compare the OC symptom distribution between GTS and OCD and to investigate whether a subdivision of these phenomena into obsessions, compulsions and ‘impulsions’ is useful in distinguishing GTS and OCD patients. Thirty-two GTS, 31 OCD (10 with tics, 21 without tics) and 29 control subjects were studied using the Leiden repetitive behaviors semi-structured interview to assess GTS as well as OCD-related behaviors. Each reported repetitive thought or action was evaluated on the presence of anxiety and on goal-directedness. This information was used to define whether the behavior was an obsession, compulsion, or ‘impulsion’. Both the GTS and OCD study groups showed higher scores than control subjects on rating scales measuring depression, OC behavior and anxiety. In GTS, Y–BOCS severity scores and trait anxiety were lower than in the OCD groups. Furthermore, GTS patients differed from OCD patients in the distribution of symptoms. Aggressive repetitive thoughts, contamination worries and washing behaviors were reported more frequently by tic-free OCD, while mental play, echophenomena, touching and (self)-injurious behaviors were reported more frequently by GTS. OCD individuals with tics were intermediate, but closer to tic-free OCD. GTS individuals reported significantly more ‘impulsions’ and fewer obsessions and compulsions than OCD individuals with and without tics. Factor analysis revealed three factors accounting for 44% of the variance, resulting in an ‘impulsive’ factor related to GTS, a ‘compulsive’ factor related to OCD and an ‘obsessive’ factor related to tic-free OCD. In conclusion, OCD individuals reported more anxiety and goal-directedness associated with their behaviors than did GTS subjects. The distinction between obsessions, compulsions and impulsions is of importance in identifying Tourette-related vs. non-Tourette-related repetitions.

Gilles de la Tourette syndrome (GTS) is characterized by motor and vocal tics. In addition, obsessions, compulsions and ‘Tourette-related’ repetitions co-occur. The essential features of obsessive–compulsive disorder (OCD) are recurrent and persistent ideas, thoughts or impulses that are experienced as being intrusive and cause marked distress or anxiety (obsessions), and/or repetitive behaviors aimed at the reduction of distress or anxiety (compulsions). Phenomenological and family-genetic studies support an interrelationship between GTS and OCD. Obsessive–compulsive symptoms are found in 28–63% of patients with GTS (Grad et al., 1987, Robertson et al., 1988, Pitman et al., 1987 and Apter et al., 1993), and an increased prevalence of OCD is reported in first-degree relatives of GTS probands, independently of concurrent OCD in these probands (Pauls et al., 1986 and Pauls et al., 1991). Family studies of OCD probands revealed tics in at least 17% of adult patients and increased rates of tics in their first-degree relatives (Holzer et al., 1994 and Pauls et al., 1995). However, OCD seems to be etiologically heterogeneous, with only a tic-related form of OCD being associated with GTS (Pauls et al., 1995). Neurochemical data on the relationship between GTS and OCD are contradictory, but GTS and tic-related OCD seem to exhibit a different reaction to serotonin reuptake inhibitors from tic-free OCD (McDougle et al., 1994). The exact delineation of GTS and OCD subgroups is important because the different subtypes might be related to different treatment responses and genetic transmission. One way to delineate GTS from OCD subgroups is to compare their obsessive–compulsive symptomatology. Mental play, echophenomena, touching, symmetry behaviors and self-injurious behaviors are found more frequently in GTS and tic-related OCD (Cath et al., 1992a, Cath et al., 1992b, George et al., 1993 and Holzer et al., 1994). OCD patients with tics, when compared with OCD without tics, reveal more violent images and impulses, a fear of saying ‘inappropriate’ things, a need to know/remember, checking, counting, ordering, hoarding, touching, tapping, trichotillomania, and rubbing behaviors. In contrast, OCD patients without tics report more contamination worries and washing behaviors (Leckman et al., 1994a, Holzer et al., 1994 and Eapen et al., 1997). Miguel et al. found that OCD patients reported more cognitions and autonomic anxiety, and fewer sensory phenomena were associated with the repetitive behaviors than GTS patients, while tic-related OCD patients scored intermediately between GTS and OCD (Miguel et al., 1995 and Miguel et al., 1997). The authors suggest that sensory phenomena preceding repetitive behaviors in tic-related OCD are important in distinguishing them from tic-free OCD, while accompanying anxiety and cognitions distinguish tic-free from tic-related OCD. Underlying behavioral patterns have been studied with the aid of factor analysis. Although OC symptom patterns can change within the patient during the course of the illness (Rettew et al., 1992), specific symptom clusters are possibly related to tic-related vs. tic-free OCD. Baer (1994) performed factor analysis on 107 OCD subjects using the Yale–Brown Obsessive–Compulsive Scale (Y–BOCS) symptom checklist, and found that three factors best explained the checklist categories. Leckman et al. (1997) replicated and extended these findings and found four factors. While Baer's results suggest one factor containing symmetry and hoarding behaviors, the findings reported by Leckman et al. suggest that this factor is divided into one characterized by symmetry and another by hoarding behaviors. Both reported that the factor characterized by symmetry behaviors was observed more often in OCD subjects with tics. Phenomenological research is hampered by difficulties in defining and differentiating the various repetitive phenomena of GTS. The most widely used checklist on OC behaviors, the Yale–Brown Obsessive Compulsive Scale (Y–BOCS) symptom checklist (Goodman et al., 1989a and Goodman et al., 1989b), is suitable as a checklist for anxiety-related OC items, but it bears a risk of not giving due weight to non-anxiety-related repetitions, as many items on this checklist pre-suppose anxiety-relatedness. Furthermore, some possibly ‘Tourette-related’ items, such as the need to touch, tap or rub, are grouped under the category ‘miscellaneous’ thoughts or actions. In some studies, this category is excluded from analysis (Holzer et al., 1994), which further increases the risk of underscoring ‘Tourette-related’ items. To address these methodological problems, we have chosen to investigate the repetitive phenomena in GTS and OCD in a more neutral way, defining them as ‘stereotyped repetitive behaviors’. Shapiro et al. (1988) argued that repetitive thoughts and actions in GTS are performed automatically, or as the consequence of a failure to resist an impulse. They considered the Tourette-related repetitive phenomena essentially as non-anxiety-related. Hence, they suggested that these behaviors be called impulsions as opposed to compulsions which, according to diagnostic convention, are aimed at anxiety reduction. However, the proposal for the terminology of impulsions has not elicited enough enthusiasm to be generally accepted, and different terms have been applied to these repetitive behaviors such as: ‘Tourette-related’ OC behaviors, cognitive tics, complex motor tics, or ‘tic-like’ compulsions. In this study, we have focused on investigating whether the subdivision of repetitive phenomena into obsessions, compulsions, and ‘Tourette-related’ impulsions is useful in distinguishing tic-related obsessive–compulsive patients from non-tic-related patients. In line with Shapiro et al., we defined impulsions as stereotyped repetitive thoughts or actions that are not anxiety-related. Anxiety-relatedness is determinative of whether a repetitive thought or action is to be considered an impulsion or not. Another characteristic of an impulsion is that the behavior is stimulus-bound, resulting in an increased tendency to act upon provocative visual, auditive, tactile, sensory or cognitive stimuli. Diverging from Shapiro's concept, in which another criterion for an impulsion is its automatic, aimless character, we did not include this criterion in our definition of impulsions. To delineate impulsions from obsessions and compulsions is consistent with a hypothesis on OCD spectrum disorders, although the concept of impulsions bears the risk of over-inclusiveness, because it is based on the absence of anxiety-relatedness. OCD spectrum disorders refer to a variety of different disorders that share characteristics with OCD, including symptom overlap, family history, neurobiological features, clinical course and treatment response (Hollander, 1993, Oldham et al., 1996 and Goldsmith et al., 1998). OC spectrum disorders are viewed along a continuum with a compulsive risk-aversive pole at one end and an impulsive risk-seeking pole at the opposite end. In this scheme, OCD with predominant obsessions and compulsions is positioned at the compulsive end, whereas GTS with both ‘Tourette-related’ impulsions, as well as obsessions and compulsions, is positioned slightly towards the impulsive pole. In the present study, we hypothesized that: (1) repetitive behaviors can be categorized according to the criterion of anxiety-relatedness into obsessions and compulsions on the one hand, and impulsions on the other hand; and (2) they are distributed differently in GTS and OCD. Anxiety-related obsessions and compulsions occur more frequently in tic-free OCD, while non-anxiety-related impulsions occur more frequently in GTS. Tic-related OCD is positioned intermediately between GTS and tic-free OCD, sharing repetitive behaviors of both disorders.

3.1. Patient characteristics and rating scale scores Patient characteristics and rating scale scores are summarized in Table 2. The control group was older (P: 0.001–0.04). The GTS group had a longer duration of illness than the OCD groups (P:<0.001–0.04). Ten OCD subjects (32%), comprising the tic-related OCD (OCD+tic) group, either performed or had a lifetime diagnosis of chronic motor tics. One control subject (3%) had a chronic motor tic. Fourteen GTS subjects (43%) had concurrent OCD, according to the CIDI. The tic-related OCD group was younger (P=0.04) than the tic-free OCD group (containing OCD patients without a lifetime history of tics). GTS and OCD subjects used more antipsychotic medication than control subjects (P=0.001 and 0.05, respectively) Tic-free OCD subjects used more antidepressant medication than GTS patients and OCD+tic patients (P=0.006 and 0.004, respectively). The control group used more pain-alleviating medication to control lower back pain than GTS and OCD patient groups (predominantly non-steroid anti-inflammatory drugs; P=0.009 in both cases). Table 2. Patient characteristics and rating scale scores: GTS vs. OCD±ticsa GTS (n=32) OCD+tics (n=10) OCD no tics (n=21) Control subjects (n=29) Differences between groups n mean S.D. n mean S.D. n mean S.D. n mean S.D. GTS/ GTS/ GTS/ OCD OCD/ (%) (%) (%) (%) OCD OCD control +tics/ control +tics no tics subjects OCD subjects P P P no tics P P Patient characteristics Age (years) 34 13.7 26.1 9 35.7 8.7 45 11.9 n.s n.s 0.002 0.04 0.001 Male gender 17 (53) 5 (50) 9 (43) 11 (38) n.s n.s n.s n.s n.s Illness duration (years) 24.5 15.5 7.5 4.5 15.8 11.6 11.1 13.1 <0.001 0.04 <0.001 n.s n.s Tics 32 (100) 10 (100) 0 (0) 1 (3) n.s <0.001 <0.001 <0.001 n.s Current medication Neuroleptics 10 (31) 1 (10) 4 (19) 0 (0) n.s n.s 0.001 n.s 0.05 Antidepressants 2 (6) 3 (30) 9 (43) 0 (0) n.s 0.006 n.s 0.004 <0.001 Pain alleviation 0 (0) 0 (0) 2 (9.5) 6 (21) n.s n.s 0.009 n.s 0.009 Rating scale scores MADRS 8.8 7 13 9 9 7 3.7 3.7 n.s n.s 0.002 n.s 0.001 Y–BOCS 15.3 7.2 24 7 21 6 2.5 3.7 0.006 0.004 <0.001 n.s <0.001 LOI 83.8 20.2 94 22 90 20 59.4 11.7 n.s n.s <0.001 n.s <0.001 A-GAF (%) 75.3 11.6 65 13 68 10 85.8 5.6 0.04 0.035 <0.001 n.s <0.001 EASI-III impulsivity 60.6 5.5 64.5 8 61 6 62.1 4.9 n.s n.s n.s n.s n.s STAI-state 39.7 10.2 46 9 46 11 31.4 6.1 n.s n.s 0.001 n.s <0.001 STAI-trait 47.2 10.1 57 9 52 9 31.2 5.9 0.02 n.s <0.001 n.s <0.001 a MADRS=Montgomery–Åsberg Depression Rating Scale. Y–BOCS=Yale–Brown Obsessive Compulsive Rating Scale. LOI=Leyton Obsessive–Compulsive Inventory; A-GAF=Adult version Global Assessment of Functioning Scale. EASI-III=Emotionality/Activity/Sociability/Impulsivity scale (Buss and Plomin, 3d version); STAI=State-Trait Anxiety Inventory (Spielberger). Table options The control group had lower scores than GTS and OCD on all rating scales (P between <0.001 and 0.002), with the exception of some impulsivity subscales (P=n.s.). Tic-related OCD did not differ from tic-free OCD on any of the rating scale measures (P=n.s.). The GTS and OCD groups did not differ on depression scores (P=n.s.). In GTS, Y–BOCS severity scores were lower when compared with the OCD groups (P: 0.004–0.006). Global functioning was lower in OCD±tics when compared with GTS and the control subjects (P: <0.001–0.04). Impulsivity scores revealed no significant differences between the study groups. The GTS subjects had lower trait-anxiety scores than the tic-related OCD group and higher scores than control subjects (P=0.02 and <0.001, respectively). 3.2. Phenomenology of repetitive behaviors according to the GTS–OCD interview Data on the repetitive phenomena in the GTS (n=32), OCD (n=21 without tics; n=10 with tics) and control group (n=29) are displayed in Fig. 1. All GTS and all OCD subjects reported repetitive behaviors, GTS subjects reporting, on average, five behaviors per subject (S.D.=2.7); OCD±tic subjects, four behaviors per subject (S.D.=2.3) (Z between −0.3 and 0.1; P=n.s between the groups). Eighty-three percent of the control subjects reported repetitive behaviors, control subjects reporting, on average, two behaviors per subject (S.D.=2.0) (Z between −4.4 and −3.2; P<0.001 between control subjects, GTS and OCD, respectively). Full-size image (9 K) Fig. 1. Repetitive behaviors in GTS, OCD and control subjects, according to the Leiden GTS/OCD interview. Figure options In OCD±tics, aggressive repetitive thoughts, ruminations and checking behaviors were most frequently reported; in GTS, ruminations, mental play, touching, checking, repeating, and self-injurious behaviors were found (>75% of cases). The control group reported most frequently on ruminations, mental play, and checking actions (>40% of cases). When compared with control subjects, GTS patients reported significantly more repetitive behaviors on all items (P:<0.001–0.04), except for contamination obsessions, washing, checking, praying and miscellaneous thoughts/actions; these occurred with similar frequencies in both groups (P=n.s.). Similarly, OCD±tic patients reported significantly more repetitive behaviors than control subjects on all items (P:<0.001–0.02), except sexual thoughts, mental play, echophenomena, symmetry, touching and praying behaviors; these behaviors occurred in similar frequencies (P=n.s.). The OCD+tic group was between GTS and tic-free OCD, closer to the tic-free group than to GTS. OCD+tic individuals reported more echophenomena (P=0.03) and fewer counting behaviors (P=0.03) than tic-free OCD subjects. Furthermore, they reported less mental play (P=0.01) and fewer touching behaviors (P=0.004), and tended to report fewer echophenomena and symmetry behaviors (P=0.07 in both items) than GTS subjects. Tic-free OCD subjects reported more aggressive thoughts (P=0.03), contamination obsessions (P=0.02), less mental play (P=0.007), fewer echophenomena (P=0.0002), touching (P=0.0001) and (self-)injurious actions (P=0.04), and tended to report more washing and checking behaviors (P=0.06 on both items) than GTS individuals. Stepwise forward logistic regression analysis (in which those symptom categories that significantly differed between GTS and OCD were entered, i.e. aggressive repetitive thoughts, contamination worries, mental play, echophenomena, washing, checking, symmetry, touching, self-injurious and miscellaneous actions) revealed that the presence of repetitive touching accurately predicted a diagnosis of GTS in 76% of cases (β=6.7; P=0.0002; sensitivity 84%; specificity 68%); entering echophenomena into the analysis equally predicted a diagnosis of GTS in 76% of cases (β=6.8; P=0.01; sensitivity 63%, specificity 90%). 3.3. Factor structure of the phenomenology in GTS and OCD patients On the basis of an exploratory principal components analysis of the symptom categories of the interview in the study group (n=92), the scree test revealed a break after the first three factors ( Table 3). These factors, characterized as ‘compulsive’, ‘impulsive’ and ‘obsessive’, accounted for 44.5% of the variance. Using factor loadings >0.40, the compulsive factor consisted of washing, checking, ruminating, contamination worries, repeating, repetitive reading/writing, and miscellaneous actions. The impulsive factor consisted of touching, echophenomena, mental play, symmetry behaviors, (self-)injurious behaviors, and repetitive reading/writing actions. The obsessive factor consisted of aggressive repetitive thoughts, repeating, counting, and praying behaviors. Table 3. Results of principal components analysis with varimax rotation of factor loadings of the symptom categories of the Leiden GTS/OCD interview on three factorsa Repetitive behaviors Factor scores Compulsive Impulsive Obsessive Repetitive aggressive thoughts 0.14 0.25 0.44* Repetitive sexual thoughts 0.16 0.40* 0.32 Contamination worries 0.69* −0.17 0.01 Ruminative thoughts 0.51* 0.38 −0.12 Mental play −0.07 0.64* 0.14 Echophenomena −0.09 0.76* 0.16 Repetitive washing/cleaning 0.67* −0.11 0.19 Repetitive checking 0.44* 0.07 0.17 Repeating actions 0.49* 0.26 0.48* Counting 0.34 0.09 0.63* Symmetry thoughts/actions 0.37 0.49* −0.10 Touching actions 0.15 0.70* 0.11 Repetitive reading/writing 0.44* 0.51* 0.05 (Self)-injurious actions 0.01 0.62* 0.06 Repetitive praying −0.29 −0.04 0.82* Miscellaneous thoughts/actions 0.61* 0.21 0.01 a Factor scores≥0.4 are marked with an asterisk *. Table options Of note is that: (1) the compulsive factor appears to be related to OCD, as factor scores were higher in OCD vs. GTS subjects (mean=−0.13, S.D.=0.8 for GTS, mean=0.7, S.D.=1.1 for OCD; P<0.01); (2) the impulsive factor appears to be related to GTS, as factor scores were higher in GTS vs. all OCD subjects, as well as separately (mean=0.8, S.D.=0.9 for GTS; mean=−0.4; S.D.=0.8 for tic-free OCD; mean=−0.1, S.D.=1.3 for tic-related OCD; P<0.001); (3) the obsessive factor appears to be related to tic-free OCD when compared to OCD with tics, as factor scores were higher in tic-free OCD (mean=0.5, S.D.=0.9 for tic-free OCD, mean=−0.3, S.D.=0.7 for tic-related OCD; P=0.02). 3.4. Repetitive behaviors classified as obsessions, compulsions or impulsions Both tic-free and tic-related OCD groups reported more obsessions and compulsions than GTS (P=0.006 and P<0.001, respectively), and fewer impulsions than GTS (P<0.001). Tic-related OCD individuals tended to report fewer impulsions than tic-free individuals (P=0.053). No other differences were observed. When compared with control subjects, both OCD and GTS subjects reported more impulsions (P=0.045 for OCD; P<0.001 for GTS), obsessions (P<0.001 for OCD; P=0.003 for GTS) and compulsions (P<0.001 for OCD; P=0.04 for GTS). Repeating actions (P=0.001), (self-)injurious behaviors (P=0.06) and miscellaneous thoughts and actions (P=0.05) were experienced differently in GTS when compared with OCD; GTS subjects experienced these items in most instances as non-anxiety-related impulsions (87.5% for repeating actions; 100% for self-injurious and tic-like actions; 67% for miscellaneous thoughts and actions), while OCD subjects experienced them as both impulsions and compulsions (40–60% for repeating; 83–17% for self-injurious behaviors; 25–75% for miscellaneous thoughts and actions). No significant differences between the groups were found for the other categories. Aggressive repetitive thoughts, contamination worries, and ruminations were experienced predominantly as obsessions; checking, washing, praying, re-reading/writing as compulsions; mental play, echophenomena, touching, symmetry behaviors as impulsions; repetitive sexual thoughts and counting actions as both impulsions and compulsions.