“Not just right experiences” in patients with Tourette syndrome: Complex motor tics or compulsions?

Abstract

Tourette syndrome (TS) is a chronic tic disorder often accompanied by specific obsessive-compulsive symptoms (OCS) or full-blown obsessive-compulsive disorder (OCD). Repetitive behaviours are commonly reported by patients with TS, who experience the urge to perform an action until it has been done “just right”. This study investigated the clinical correlates of “not just right experiences” (NJREs) in this clinical population. A standardised battery of self-report psychometric measures was administered to 71 adult patients with TS recruited from a specialist TS clinic. NJREs were systematically screened for using the Not Just Right Experiences-Questionnaire Revised (NJRE-QR). The vast majority of patients in our clinical sample (n=57, 80%) reported at least one NJRE. Patients diagnosed with TS and co-morbid OCD/OCS (n=42, 59%) reported a significantly higher number of NJREs compared to TS patients without OCD/OCS. The strongest correlation was found between NJRE-QR scores and self-report measures of compulsivity. NJREs appear to be intrinsic to the clinical phenomenology of patients with TS and can present with higher frequency in the context of co-morbid OCD/OCS, suggesting they are more related to compulsions than tics.

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.