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Life's A Twitch! Celebrating 15 years.
1998 - 2018
Life's A Twitch! Celebrating 15 years.

 

Question 104: Dear Dr. Duncan, I am a mental health professional. I read your story in the Reader's Digest of July 2004 and immediately went to your website. It is a wonderful website and provides extremely useful information. In am writing from Calcutta, India, and very little information on TS is available here. The reason for my sending this mail to you is the following:

About two months ago, a 29 year old female was referred to me for psychotherapy. She was reportedly suffering from OCD. The symptom was that she has an irresistible urge to insert her finger in her right eye. She has this symptom from age 12 and has been treated by the best psychiatrists both in America and India. Nothing has helped her beyond temporary relief. She also is on drugs for epileptic seizures which are controlled now. The girl has lost sight in her right eye and has also damaged her left eye. The symptoms decrease or increase in intensity from time to time. She does this mostly in bathrooms or places where she cannot be observed. She also has an urge to scream loudly and when she does that her mouth becomes distorted. Somehow I became a bit skeptical about the diagnosis of OCD. Her personality does not have any perfectionist trend, the anxiety-reduction after completion of the compulsive act is also not present. I am aware that it may not be present in all cases.

My questions are:
a. Is it possible that the symptom this girl is suffering from is TS and not OCD?
b. Could it in any way be related to her epileptic seizures?

Even before reading your story, in last week's session, I advised her to be aware of her urge and immediately to do something which will make her hands inactive, like putting her hands in a pair of gloves etc. I would like to help. Any suggestion will be hightly appreciated. With thanks in advance, PM.


Thank you for emailing, and for your kind words. I don't believe I've ever had anyone from India contact me before -- you mention that very little TS information is there, however if you know of any organizations created to help those with TS in your country I would be pleased to post this information on my website.

From the symptoms you describe, the amount of time she's had them, and the way in which they wax and wane (increase and decrease) it is certainly very possible that this is TS and you are perceptive to consider this. When you say that engaging in the action doesn't result in a satiation of the anxiety, is this an absolute absence? Or is it simply a fleeting or brief relief that is quickly followed up by a subsequent urge? This may be something you want to ask her.

The distinction between OCD and TS is a tricky one -- because complex tics can be indistinguishable from compulsive rituals, and because the two are highly comorbid (around 50% of those with TS also have OCD; a higher percentage at least evidence O/C behaviours) usually the only way to determine which it is is to determine what it is creating the behaviour. If the patient describes a general feeling of somatic unrest or a bodily pressure, tickle, or "itch" that requires attention this is more likely TS. If the behaviour is elicited by more of a cognition -- a thought around symmetry, worry, contamination etc. (something more coherent that elicits an anxiety) then I think more in terms of OCD.

If you are considering behavioural interventions (what you describe in your email sounds like one component of Habit Reversal Training), the distinction is not as important between TS and OCD as the behavioural treatments for both are rather similar (both Habit Reversal Training and Exposure and Response Prevention entail exposure to the precipitating event i.e. either the intrusive cognition in OCD or the rising premonitory urge in TS) and preventing engaging in the connected behaviour. To purchase a youth-friendly manual on how to use Habit Reversal Training (or what is now known as the Comprehensive Behavioral Intervention for Tics / CBIT), click here.

If you are considering pharmaceutical intervention, it is MORE important to distinguish which disorder it is as antidepressants (SSRI's or clomipramine) are the appropriate medications to first try in OCD, but antipsychotic medications or antihypertensives are the appropriate medications to first try in TS.

While epilepsy and TS can certainly co-occur, significant connections between epilepsy and TS have never been found to the best of my knowledge. Certainly the neurophysiology of the two conditions is currently believed to be quite different.

Obviously there is an enormous amount of information regarding the differential diagnosis of either/both TS and OCD; this forum can only allow for a cursory response. I would recommend contacting the Tourette Syndrome Foundation of Canada (1-800-361-3120, or rosie@tourette.ca) to request one of their "Guide to Diagnosis and Treatment of Tourette Syndrome" manuals for more information, or go to the Tourette Syndrome Association's website (www.tsa-usa.org) to purchase some of their videos or literature as well.

I hope this, although brief, is somewhat helpful. If you need more information on HRT there is some good research literature describing it -- if you cannot access it let me know and I can send you something. THANK YOU for taking the time to learn more about this condition -- I have no doubt that by doing so you will be a saviour to many, many individuals in your country.

Dr. Dunc.

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Last updated on March 25, 2022

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