“Not just right experiences” in patients with Tourette syndrome: Complex motor tics or compulsions?
Introduction
Tourette syndrome (TS) is a neurodevelopmental condition characterised by the presence of multiple motor tics and at least one phonic tic for a minimum of 1 year (Robertson, 2000). Tics are considered involuntary in nature and usually develop between 5–7 years of age, with presenting characteristics which can be simple or complex (Robertson, 2011). TS has significant associations with co-morbid conditions, in particular obsessive-compulsive symptoms/obsessive-compulsive disorder (OCS/OCD) and attention-deficit hyperactivity disorder (ADHD) (Cavanna et al., 2009). Repetitive behaviours are observed in as many as 65% of patients with TS and can be classified as ‘tic-like’ or ‘OCD-like’ symptoms, according to the clinical phenomenology (Worbe et al., 2010). For example, OCD and compulsions are associated with a sense of responsibility for failing to carry out the behaviour, clearly distinct from the subjective experience which accompanies tics in TS (Cath et al., 2001a, Worbe et al., 2010). This is reflected in well-known differences in the clinical phenomenology of repetitive symptoms: for example, washing is more commonly related to primary OCD, while counting, need for symmetry and touching are often associated with the diagnosis of TS (George et al., 1993, Worbe et al., 2010).
“Not just right experiences” (NJREs) often result in repetitive behaviours, as patients experience the need to reiterate an action until it has been done “just right”, and are considered qualitatively different to the “premonitory urges” which characteristically precede tics (Leckman et al., 1994). Limited research using specific measures has been performed to characterise these experiences in TS and OCD populations. Evidence to date conflicts, with some studies suggesting that NJREs belong more to the ‘tic-like’ than ‘OCD-like’ symptom groups (Eapen et al., 1997, Worbe et al., 2010). However, other research has shown that these experiences are more common in patients with TS and co-morbid OCD (Leckman et al., 1994, Miguel et al., 2000). Moreover, previous research specifically addressing NJREs has typically been conducted on non-clinical populations (Coles et al., 2003, Coles et al., 2005) or patients with OCD (Chik et al., 2010, Ghisi et al., 2010). Therefore, further research in patients with TS using a specific and validated measure is needed to clarify whether NJREs are more associated with complex motor tics or compulsions (OCS). A more accurate nosological classification of these behaviours would have clinical relevance in terms of improving diagnostic accuracy and choosing the most appropriate treatment interventions (Ghisi et al., 2010).
In the present study, we set out to determine whether NJREs are more associated with motor tics or compulsions by comparing the total number of NJREs in patients with TS+OCS/OCD and TS-OCS/OCD. This study also aimed to investigate associations between total number of NJREs and measures of tic and behavioural symptoms severity.
Section snippets
Participants
Patients were consecutively recruited from the specialist TS Clinic, Department of Neuropsychiatry, Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) and University of Birmingham. Patients were excluded if they were under 16 years of age, had significant learning disabilities as assessed by their treating consultant or did not have a formal diagnosis of TS according to DSM-IV TR criteria (American Psychiatric Association, 2000). The study was approved by the National Research
Sample characteristics
A total of 106 patients were initially recruited, however 35 participants were excluded from the analyses because they had not completed all psychometric measures. The demographic and clinical details for the study sample (n=71) are shown in Table 1. Tic severity (YGTSS) scores for the total sample were distributed as follows: Mild (0–25)=10%; Moderate (26–50)=38%; Marked (51–75)=46%; Severe (76–100)=6%.
NJREs in patients with Tourette syndrome and obsessive compulsive symptoms/disorder
At least one NJRE was reported in 80% of the patients who completed the NJRE-QR. The most
Discussion
We conducted the first study to systematically investigate the clinical characteristics of NJREs using a specific measure in patients with TS. The estimate of diagnostic reliability and mean tic severity of our clinical sample were consistent with those expected from a specialist TS clinic population (Leckman et al., 1989, Robertson et al., 1999). This study found that 80% of participants described one or more NJREs, most commonly that words did not sound “just right”, which is consistent with
Acknowledgements
The authors would like to thank Dr Sayeed Haque for statistical advice, Ms Eleanor Crossley for contribution to dual data entry and all participants who agreed to take part in the research. Gratitude is also expressed to Tourettes Action-UK and USA-TSA for their continuing support.
References (37)
- et al.
Repetitive behaviours in Tourette's syndrome and OCD with and without tics: what are the differences?
Psychiatry Research
(2001) - et al.
What do low-dysfunctional beliefs obsessive-compulsive disorder subgroups believe?
Journal of Anxiety Disorders
(2010) - et al.
“Not just right experiences”: perfectionism, obsessive-compulsive features and general psychopathology
Behaviour Research and Therapy
(2003) - et al.
Not just right experiences and obsessive-compulsive features: experimental and self monitoring perspectives
Behaviour Research and Therapy
(2005) - et al.
Sensory phenomena associated with repetitive behaviors in obsessive-compulsive disorder: an exploratory study of 1001 patients
Psychiatry Research
(2012) - et al.
In search of specificity: “Not just right experiences” and obsessive-compulsive symptoms in non-clinical and clinical Italian individuals
Journal of Anxiety Disorders
(2010) - et al.
The Yale Global Tic Severity Scale: initial testing of a clinician-rated scale of tic severity
Journal of the American Academy of Child and Adolescent Psychiatry
(1989) - et al.
Not just right experience: is it influenced by feelings of guilt?
Journal of Behavior Therapy and Experimental Psychiatry
(2008) - et al.
Moving beyond an exclusive focus on harm avoidance in obsessive compulsive disorder: considering the role of incompleteness
Behavior Therapy
(2008) - American Psychiatric Association, 2000. Diagnostic and statisticalmanual of mental disorders, Fourth Edition, Text...
The relationship between types and severity of repetitive behaviours in Gilles de la Tourette's disorder and obsessive compulsive disorder
Journal of Clinical Psychiatry
Gilles de la Tourette's Syndrome with and without obsessive-compulsive disorder compared with obsessive-compulsive disorder without tics: which symptoms discriminate?
Journal of Nervous and Mental Disease
The Gilles de la Tourette Syndrome Quality of Life Scale (GTS-QoL): development and validation
Neurology
The behavioural spectrum of Gilles de la Tourette syndrome
Journal of Neuropsychiatry and Clinical Neurosciences
Dissecting the Gilles de la Tourette spectrum: a factor analytic study on 639 patients
Journal of Neurology, Neurosurgery and Psychiatry
Obsessive compulsive symptoms in Gilles de la Tourette syndrome and obsessive compulsive disorder: differences by diagnosis and family history
American Journal of Medical Genetics
Clinical correlates of quality of life in Tourette syndrome
Movement Disorders
Quality of life in young people with Tourette syndrome: a controlled study
Journal of Neurology
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2018, Neuroscience and Biobehavioral ReviewsCitation Excerpt :On the contrary, in children with TS, comorbidity of OCD was associated with more severe OCS in later age and these symptoms were more likely to persist than tic symptoms (Bloch et al., 2006b). In terms of quality of life, there is evidence to suggest lower quality of life in co-morbid patients (Neal and Cavanna, 2013; Rizzo et al., 2014) (Table 5). TD was also found to be significantly more represented than other psychiatric comorbidities in OCD patients with suicide attempts (Dell’Osso et al., 2018).
Sensory aspects of Tourette syndrome
2018, Neuroscience and Biobehavioral ReviewsCitation Excerpt :Increased rates of premonitory urges are reported in patients with TS and co-morbid OCD when compared to those with TS alone (Eddy and Cavanna, 2013c; Rajagopal et al., 2013; Sambrani et al., 2016). A large paediatric study found a strong positive correlation between premonitory urges and “not just right” experiences (Sambrani et al., 2016), which appear to be intrinsic to the phenomenology of TS and commonly associated with co-morbid obsessive-compulsive symptoms (Neal and Cavanna, 2013a). A recent study (Kano et al., 2015) involving 41 patients with TS showed significant positive correlation between PUTS and DY-BOCS scores, suggesting that patients who experience more obsessive-compulsive symptoms also experience more severe premonitory urges.