Dr Osman MalikConsultant Child & Adolescent Psychiatrist

Children’s Neurosciences, Evelina LondonSt Thomas’ Hospital, London

Tics, OCD and Autism

Outline

• What are Tics and Tourette Syndrome (TS)

• How common are Tics and TS in individuals with ASD

• Specific challenges and factors to consider when managing Tics inASD

• What is Obsessive Compulsive Disorder (OCD)

• OCD and ASD are different but there are some overlaps

• How common is OCD in individuals with ASD

• Specific OCD treatment challenges with co-occurring ASD

Definitions: Tics/Tourette

• Tics: described as a stereotyped, repeated (but not rhythmic) usuallyrapid and brief movements or vocalization (Freeman)

• Tics: Sudden, rapid, repetitive, non-rhythmic, inapposite, irresistible,muscle movements of vocalizations, which can be classified assimple or complex (Cath et al 2011, Singer 2011)

• Tics: are suppressible, suggestible, waxing and waning and have apremonitory urge.

Tourette Syndrome (TS)*

• multiple (2 or more) motor tics

and

• one or more vocal tics

• both present at the same time (but not necessarily simultaneously) forat least 1 year

• a waxing and waning course

• onset before 18

and

• not attributable to effects of a substance or other medical conditions

* (DSM-5, American Psychiatric Association 2000)

Course and prognosis of Tics

• Tics are benign neurological movements.

• Tics wax-and-wane over time and move around to different parts of the

body. New tics emerge and some old ones disappear but this does not

indicate that the condition is getting worse, rather is the natural course of the

condition.

• Tics are usually at their peak between ages 10 and 13. After 13 they tend to

reduce in a fluctuating manner.

• In about 55-60% of young people tics disappear by late teens - early

adulthood. In another 20-25% tics become minor or minimal. In around

20% the tics continue into adulthood with the same severity.

• For most young people the mainstay of managing tics is to ignore them

entirely.

Tics and ASD

• Previously tics in ASD were considered coincidental or caused byneuroleptic medication (Barabas et al, Mueller et al, Realmuto et al, Stahl et al).

• However, an increasing number of clinical reports (Comings et al, Ringman et

al, Sverd et al) and systematic studies (Baron-Cohen et al, Burd et al, Canitano et al,

Sverd et al) established that tics (and TS) in ASD were common.

• A significant proportion of TS patients have ASD (currently 4.5%–12.9%, but estimates in studies vary from 3-20%) – (Freeman et al 2000,

Burd 2009 et al, Pringsheim 2013 et al)

Tics and ASD

• In ASD - tic phenomenology, tic awareness, and associated sensoryphenomena is not well studied.

• The tic severity in ASD is reported to be usually mild (Canitano 2007, Baron-

Cohen 1999, Pringsheim 2013) but our experience at Evelina differs.

• The presence of ASD in TS, is associated with higher comorbidity rates forADHD, rage attacks, and OCD (Pringsheim 2013).

• There are implicated common genetic factors behind both ASD and TS(Clarke et al, Lawson-Yuen et al, Fernandez et al, State et al) and similarities inneuroimaging findings (Church 2005, Courchesne 2005, Hughes 2007)

Tics and Tourette syndrome in autism spectrum disorders.Canitano et al. Autism, 2007; 11(1), 19–28.

• Among 104 individuals with ASD, 22 percent presented ticdisorders:

• 11 percent with Tourette disorder (TD), and 11 percent with chronicmotor tics.

• An association between the level of intellectual impairment and ticseverity was found.

Psychopathology in a Swedish population of school children withtic disorders. (Khalifa et al 2006)

• Another epidemiological study conducted in Sweden on a population of4479 children measured a 0.6% frequency of TS.

• In the TS group:

1. The rate of comorbid ADHD 68% (60% combined subtype, 8% hyperactive-impulsive subtype)

2. The rate of ASD was 20% (16% Asperger, 4% PDD-NOS)

3. The rate of dyslexia was 16%

4. The rate of developmental coordination disorder was 20%

Studies of TS in ASD samples, and ASD in TS samples

Challenges that tics present for young people with Autism:

• Increase in social anxiety when tic-ing in public

• Misunderstanding of the tics and coprolalia – effects of social awareness onmodulation of eco and coprophenomena

• High levels of baseline anxiety and emotional dysregulation can result inintense bouts of tics

• Increased sensitivity to tic-urge perception: the role of sensory sensitivitiesand higher level of interoception in tic frequency and severity

• Tic attacks and attacks of Tic-like movements in young people with AutismSpectrum Disorder

Tic-attacks: are they a form of functional neurologicaldisorder?

• Collicott and colleagues used the term tic-attacks to describe ‘distinct boutsof severe, continuous, non-suppressible and disabling tics lasting from 15minutes to several hours’.

• In child and adolescent samples the movements seen in tic attacks includeboth tics as well as whole body writhing that is inconsistent with tics.

• Tic-attacks are a mixture of severe bout of typical tics combined withfunctional anxiety driven movements mostly full body writing movements –so these may be better described as attack of tic-like movements andpresent a common form functional movement in tics.

• Represent a panic attack in an individual with tics and co-morbid anxiety.

Trigger stimulusPremonitory urge: tingling in spine

Perceived Threat“I might have a tic”

“What will others think?”

Anxiety/ApprehensionWill it happen?

Body sensationsElevated heart rate, sweating, legs

weaken

Internal MonitoringBody Scanning

Interpretation of sensation ascatastrophic

Safety behavioursMove to safe position,hold wall, avoidance

Tic-attack management

• Difficult for a parents to observe and parental focus on the tic-likeattacks can maintain and reinforce these.

• Often triggered in the mornings, before going to school, or at night,or in social situations

• Children may get taken to the emergency department and are givenbenzodiazepines.

• Responds to complete diversion of attention away from the attack and theyoung person learning to externalize their attention /focus from their body toexternal stimuli and learning cognitive behaviour strategies to manage panicand anxiety (Robinson, Hedderly 2015, 2016)

Relevant characteristics in young people with attacks of tic-like movements

• Alexithymia: Inability or deficient ability to recognise, feel and describeemotions/ reduced emotional awareness

• Emotional dysregulation: a pervasive pattern of poorly modulated orexcessive emotional responses (and behavioural responses) to emotivestimuli or distress

• Intolerance of uncertainty: a temperamental or dispositional characteristicin an individual which makes them react negatively on an emotional,cognitive, behavioural level to uncertain situations/ events.

• High interoception: A sense of the internal state of the body, heightenedawareness of internal stimuli

• Psychiatric co-morbidity: higher rates of anxiety/ depression

Differentiating between Tics and Motor Stereotypies

• Age of onset

• Waxing and waning pattern

• Types of movements

• Ease of distraction

• Function of the movements

• Subjective description of movement

• Why differentiate ?

Obsessive Compulsive Disorder

• Obsessions: recurrent or persistent thoughts, urges or images that areintrusive and unwanted and cause marked anxiety or distress. Theindividual tries to neutralize the thoughts, urges or images with other actionsor thoughts.

• Compulsions: repetitive behaviours such as washing, checking or mentalactivities done to neutralize the obsessions.

• The compulsive behaviours or compulsive mental acts are aimed atpreventing or reducing anxiety or distress or preventing some dreadedevent or situation.

• The obsessions and compulsions can be time consuming, cause clinicallysignificant distress and cause impairment in social or other functioning ofthe suffering individual.

OCD and Autism

• Compulsions in OCD vs Repetitive / Ritualistic behaviours in ASD

• What are the drivers of compulsions and drivers of stereotyped / repetitivebehaviour

• Egosyntonic vs Egodystonic behaviours

• A spectrum of phenomenon: Tics/ Motor stereotypies or stereotypedbehaviours/ ritualistic behaviours/ habits/ compulsions with out obsessionsand with obsessions.

Estimates of the prevalence

• Any anxiety disorder among children and adolescents with autismspectrum disorder (ASD) 11% to 84% (wide variation – dependingon the study)

• OCD in individual with ASD: 2.6% to 37.2% (Postorino et al Emory University

Department of Pediatrics and of the Marcus Autism Centre, Atlanta) – ave 5-8 %

OCD and ASD

• Most individuals with OCD do not have ASD and most individuals with ASDdo not have OCD ….However there are some overlaps:

• OCD is more common than expected among relatives of persons withautism (Bolton et al., 1998; Micali et al., 2004).

• OCD is more common in parents of those children with autism that scoredhigh on repetitive behaviour and stereotypies (Hollander et al., 2003).

• Hoarding is commonly reported in ASD (McDougle et al., 1995).

• People with ASD have higher rates of receiving a diagnosis of OCDthan neurotypical individuals (prevalence: 8.2 - 5% vs 2.3%)

• People with OCD have a higher chance (up to 4 times higher) of havinga diagnosis of ASD

• Genetic links between OCD and ASD (Meier et al 2015)

• Another genetic study linking treatment resistant OCD with Aspergersyndrome and autism (Ozaki et al., 2003).

Using the OCI to discriminate between OCD, ASD andASD+OCD*

• Individuals with ASD (n = 171), OCD (n = 108), ASD + OCD (n = 54) and control participants (n = 92) completed the Obsessive Compulsive Inventory Revised (OCI R).

• Individuals with ASD + OCD reported significantly higher levels of obsessive compulsive symptoms than those with ASD alone.

• OCD symptoms were not significantly correlated with core ASD repetitivebehaviours as measured on the ADI R or ADOS.

• Authors concluded that OCD manifests separately from ASD and ischaracterized by a different profile of repetitive thoughts and behaviours.

*Cadman et al. Autism Res 2015, 8: 477–485. © 2015 International Society for Autism Research

Other useful scales

• Children's Yale-Brown Obsessive Compulsive Scales (CYBOCS)

• Children's Yale-Brown Obsessive Compulsive Scales for ASD (CYBOCS-ASD)

Symptom Overlap between Autism SpectrumDisorder, Social Anxiety Disorder andObsessive-Compulsive Disorder in Adults (Cath et al 2006)

• Authors use the Autism Quotient (AQ) to discriminate between 3 groupsASD vs OCD vs SAD

• Total scores on the AQ for ASD group was the highest

• The sub-scale that really differentiated the ASD group was imaginationsubscale

• ASD group also scores higher in the communication and attention switching

• Authors however found an over-lap of symptoms as well

Does OCD have an ASD subtype (Bejerot)

• There is a distinct form of OCD in Tics (Holzer et al., 1994; Leckman et al., 1994).

• OCD in Tics is mostly compulsions only and includes symptoms such assymmetry, ordering, blinking, tapping, touching, rubbing and staring rituals(Mataix-Cols et al., 1999,2008), but also with checking, counting and hoarding, atleast among adolescents (Leckman et al., 1994).

• A tic-related OCD subtype seems reasonably validated – so could OCD withcomorbid ASD a valid OCD subtype?

• McDougle et al.(1995) reported that specific symptoms such as repetitiveordering, hoarding, touching, tapping, rubbing and self-injurious behaviourswere significantly more frequent among persons with autism than amongpersons with OCD.

• Russell et al. (2005) 10 out of 40 subjects with ASD and averageintelligence had OCD and 12 were hoarders.

• But currently there is no agreed OCD sub-type in ASD

ASD risks being missed or misunderstood whenco-morbid with OCD

• Obsessional slowness, a treatment resistant form of OCD, could be viewedas a form of catatonia – and catatonia is common in ASD (Wing and Shah,2000).

• ASD may also be misinterpreted as social phobia, generalized anxietydisorder, delusional disorder or dysthymia (Gillberg and Billstedt, 2000) oreven more often as personality disorders.

Personality disorder diagnosis in OCD could be amisdiagnosis of ASD with OCD

• In OCD, the reported prevalence of categorical personality disordersranges between 33 and 87 percent.

• The most common are avoidant, dependent and obsessive-compulsivepersonality disorders (Baer et al., 1992)

• Cluster A (eccentric: schizoid, schizotypal and paranoid personality)disorders are more prevalent in OCD patients than in other non-psychoticpatients (Rossi and Daneluzzo, 2002).

Personality disorder diagnosis in OCD could be amisdiagnosis of ASD with OCD

• Stanley et al. (1990) reported schizotypal features in 28 percent of his OCDcases.

• Since schizotypal personality disorder, at least as defined by Westen andShedler (1999), is primarily a description of autistic traits, and Rutter (1987)has suggested that the schizoid personality pattern in childhood is Aspergersyndrome.

• The resemblances between obsessive-compulsive (anankastic) personalitydisorder and ASD, especially Asperger syndrome, were pointed out byGillberg and Billstedt (2000).

OCD treatment challenges in ASD

• Nature of compulsions

• Desire to undo a past event

• Rigidity of compulsions

• Distress induced by the intrusive obsessional thoughts

• Recall of imperfect compulsions

• Over-analytic thinking style

• Central coherence

Summary

• Up to 22 % of young people with ASD have Tics and at least half of theseare chronic tics and average 6.2 % have Tourette Syndrome.

• There are unique challenges for individuals with Tics and ASD together

• Up to 30 % of young people with ASD can have OCD although averagefigure is 5-8 %

• There are unique challenges for individuals with OCD and ASD includingtreatment challenges.

• Individuals with identified OCD who have undiagnosed ASD are often notrecognised and go on to have treatment resistant OCD or get otherdiagnoses such as personality disorders, and social anxiety disorder.

• Both Tics and OCD can be managed through several treatmentapproaches and therefore must be identified in individuals with ASD

References

Barabas G, Matthews WS. Coincident infantile autism and Tourette syndrome: a case report. J Dev Behav Pediatr1983;4:280–281.

Baron-Cohen S, Mortimore C, Moriarty J, Izaguirre J, Robertson M. The prevalence of Gilles de la Tourette’s syndromein children and adolescents with autism. J Child Psychol Psychiatry 1999;40:213– 218.

Baron-Cohen S, Scahill VL, Izaguirre J, Hornsey H, Robertson MM. The prevalence of Gilles de la Tourette syndromein children and adolescents with autism: a large scale study. Psychol Med 1999;29: 1151–1159.

Burd L, Fisher WW, Kerbeshian J, Arnold ME. Is development of Tourette disorder a marker for improvement inpatients with autism and other pervasive developmental disorders? J Am Acad Child Adolesc Psychiatry1987;26:162–165.

Burd L, Li Q, Kerbeshian J, Klug MG, Freeman RD. Tourette syndrome and comorbid pervasive developmentaldisorders. J Child Neurol 2009;24:170–175.

Cath D et al. Repetitive behaviors in Tourette's syndrome and OCD with and without tics: what are the differences?Psychiatry Res. 2001 Mar 25;101(2):171-85.

Cath DC, Hedderly T, Ludolph AG, et al. European clinical guidelines for Tourette syndrome and other tic disorders.Part I: assessment. Eur Child Adolesc Psychiatry. 2011;20(4):155-71.

Canitano R, Vivanti G. Tics and Tourette syndrome in autism spectrum disorders. Autism 2007;11:19–28.

Church J, Fair D, Dosenbach N, et al. Control networks in paediatric Tourette syndrome show immature and anomalouspatterns of functional connectivity. Brain 2009;132:225–238.

Clarke R, Lee S, Eapen V. Pathogenetic model for Tourette syndrome delineates overlap with relatedneurodevelopmental disorders including autism. Transl Psychiatry 2012;2:e158.

Comings D, Comings B. Clinical and genetic relationships between autism-pervasive developmental disorder andTourette syndrome: a study of 19 cases. Am J Med Genet 1991;39:180–191.

Courchesne E, Pierce K. Why the frontal cortex in autism might be talking only to itself: local over-connectivity but long-distance disconnection. Curr Opin Neurobiol 2005;15:225–230.

Fernandez TV, Sanders SJ, Yurkiewicz IR, et al. Rare copy number variants in Tourette syndrome disrupt genes inhistaminergic pathways and overlap with autism. Biol Psychiatry 2012;71:392– 402.

Freeman RD, Fast DK, Burd L, Kerbeshian J, Robertson MM, Sandor P. An international perspective on Tourettesyndrome: selected findings from 3,500 individuals in 22 countries. Dev Med Child Neurol 2000;42:436–447.

Freeman, Roger. Text book: Tics and Tourette Syndrome : Key Clinical Perspectives. Mac Keith Press April 2015

Gillberg and, C., & Billstedt, E. (2000). Autism and Asperger syndrome: coexistence with other clinical disorders. ActaPsychiatrica Scandinavica, 102(5), 321-330.

Hughes JR. Autism: the first firm finding underconnectivity? Epilepsy Behav 2007;11:20–24.

Hollander E, King A, Delaney K, Smith CJ, Silverman JM. Obsessive-compulsive behaviors in parents of multiplexautism families. Psychiatry Res. 2003 Jan 25;117(1):11-6.

Khalifa N, von Knorring A-L. J Am Acad Child Adolesc Psychiatry. 2006;45:1346–53.

Kerbeshian J, Burd L. Asperger’s syndrome and Tourette syndrome: the case of the pinball wizard. Br J Psychiatry1986;148:731–736.

Lawson-Yuen A, Saldivar JS, Sommer S, Picker J. Familial deletion within NLGN4 associated with autism and Tourettesyndrome. Eur J Hum Genet 2008;16:614–618.

Leckman JF, Walker DE, Goodman WK, Pauls DL, Cohen DJ. "Just right" perceptions associated with compulsivebehavior in Tourette's syndrome. Am J Psychiatry. 1994 May;151(5):675-80.

Malik O, Hedderly T. Childhood tic disorders: diagnosis and management. Paediatrics and Child Health.October 2018 Volume 28, Issue 10, Pages 445–453

Mataix-Cols et al. Structure of Obsessive-Compulsive Symptoms in Pediatric OCD. Journal of the American Academyof Child & Adolescent Psychiatry. Volume 47, Issue 7, July 2008, Pages 773-778

McDougle et al. A case-controlled study of repetitive thoughts and behavior in adults with autistic disorder andobsessive-compulsive disorder American Journal of Psychiatry. June 1995. American Journal of Psychiatry 152(5): 772-7

Micali, N., Chakrabarti, S., & Fombonne, E. (2004). The broad autism phenotype: findings from an epidemiologicalsurvey. Autism, 8(1), 21-37.

Mueller J, Aminoff MJ. Tourette-like syndrome after long-term neuroleptic drug treatment. Br J Psychiatry1982;141:191–193.

Pringsheim T, Hammer T. Social behavior and comorbidity in children with tics. Pediatr Neurol 2013;49:406–410.

Realmuto GM, Main B. Coincidence of Tourette’s disorder and infantile autism. J Autism Dev Disord 1982;12:367–372.

Ringman JM, Jankovic J. Occurrence of tics in Asperger’s syndrome and autistic disorder. J Child Neurol 2000;15:394–400.

Robinson, S., & Hedderly, T. (2016) Novel psychological formulation and treatment of “tic attacks” in Tourettesyndrome. Frontiers in Paediatrics, 4:46. doi: 10.3389/fped.2016.00046

Singer HS. Tourette syndrome and other tic disorders. Handb Clin Neurol. 2011;100:641-57.

Stahl SM. Tardive Tourette syndrome in an autistic patient after long-term neuroleptic administration. Am J Psychiatry1980;137:1267– 1269.

State MW. The genetics of child psychiatric disorders: focus on autism and Tourette syndrome. Neuron 2010;68:254–269.

Sverd J, Montero G, Gurevich N. Brief report: cases for an association between Tourette syndrome, autistic disorder,and schizophrenialike disorder. J Autism Dev Disord 1993;23:407–413.

Sverd J. Tourette syndrome and autistic disorder: a significant relationship. Am J Med Genet 1991;39:173–179.

Wing, L., & Shah, A. (2000). Catatonia in autistic spectrum disorders. British Journal of Psychiatry, 176(4), 357-362.doi:10.1192/bjp.176.4.357