Elsevier

Psychiatry Research

Volume 170, Issue 1, 30 November 2009, Pages 32-42
Psychiatry Research

Review article
Tourette's syndrome, trichotillomania, and obsessive–compulsive disorder: How closely are they related?

https://doi.org/10.1016/j.psychres.2008.06.008Get rights and content

Abstract

The question of whether Tourette's syndrome (TS) and trichotillomania (TTM) are best conceptualized as obsessive–compulsive spectrum disorders was raised by family studies demonstrating a close relationship between TS and obsessive–compulsive disorder (OCD), and by psychopharmacological research indicating that both TTM and OCD respond more robustly to clomipramine than to desipramine. A range of studies have subsequently allowed comparison of the phenomenology, psychobiology, and management of TS and TTM, with that of OCD. Here we briefly review this literature. The data indicate that there is significant psychobiological overlap between TS and OCD, supporting the idea that TS can be conceptualized as an OCD spectrum disorder. TTM and OCD have only partial overlap in their phenomenology and psychobiology, but there are a number of reasons for why it may be useful to classify TTM and other habit disorders as part of the obsessive–compulsive spectrum of disorders.

Introduction

The question of whether Tourette's syndrome (TS) and trichotillomania (TTM) are best conceptualized as obsessive–compulsive spectrum disorders has been raised by family studies on the close relationship between TS and obsessive–compulsive disorder (OCD) (Pauls et al., 1986, Rosario-Campos et al., 2005), and by psychopharmacological research indicating that both TTM and OCD respond more robustly to clomipramine than to desipramine (Zohar and Insel, 1987, Swedo et al., 1989). A range of studies have subsequently allowed comparison of the phenomenology, psychobiology, and management of TS and TTM, with that of OCD. These disorders are characterized by repetitive behaviors and may have a number of phenomenological intersections as depicted in Fig. 1 (Lochner et al., 2005, Chamberlain et al., 2006, Ferrão et al., 2006). Thus, some kinds of hair-pulling resemble tic-like behaviors or compulsions insofar as they are preceded by an urge to pull and followed by a sense of relief (Fig. 1, area A) or are preceded by obsessive thoughts (Fig. 1, area B); tics and compulsions can overlap insofar as some compulsions are preceded by sensory phenomena and some tics are in response to obsessions (Fig. 1, area B); and some patients have hair-pulling, tics, and compulsions (Fig. 1, area D).

Here we briefly review the current literature on the relationship of these disorders with OCD, beginning with Tourette's syndrome, and moving on to trichotillomania.

Section snippets

Phenomenology

The main phenomenological differences between TS and OCD are presented in Table 1. In OCD, compulsions are typically performed in response to obsessive thoughts, images, or impulses. In contrast, in TS tics are not commonly preceded by obsessions. In addition, tics are sometimes performed involuntarily, whereas compulsions are always performed intentionally. Tics that are performed voluntarily and compulsions not preceded by obsessions represent an area of overlap between OCD and TS.

Trichotillomania

The question of whether trichotillomania (TTM) is best conceptualized as an obsessive–compulsive spectrum disorder was raised when clomipramine was reported to be more effective than desipramine for patients with chronic hair-pulling (Swedo et al., 1989). This thought-provoking study replicated findings that serotonin reuptake inhibitors were more robust than noradrenaline reuptake inhibitors in the treatment of obsessive–compulsive disorder (OCD) (Zohar and Insel, 1987). A range of studies

Conclusion

How similar are TS and TTM to OCD? It seems clear from data on phenomenology, psychobiology, and treatment that TS and TTM are not simply variants of OCD. Nevertheless, some genetic (Pauls et al., 1996) and imaging (Moriarty et al., 1997) data indicate that TS and OCD may have significant overlap in their underlying mechanisms, and TS is arguably the disorder most closely related to OCD. In the case of TTM, there is less information available on underlying psychobiological mechanisms, but there

Acknowledgments

The authors thank Albina Torres, Alice de Mathis, Marcos Mercadante, Marcelo Hoexter, Juliana Diniz, Cristina Belloto, Antonio Carlos Lopes, Roseli Gedanke Shavitt, Ana G Hounie, and Maria Conceição Rosário, members of The Brazilian Obsessive–Compulsive Research Consortium, for their invaluable contribution to this article. The work was also supported by grants from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP, Foundation for the Support of Research in the state of São

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