Tourettic OCD? Examining Tic-Compulsion Overlap and Sensory Features in a Paediatric Case Series

INTRODUCTION Obsessive–compulsive disorder (OCD) is classically defined by intrusive obsessions accompanied by distress and compulsions aimed at alleviating anxiety.[1] Tourette’s syndrome (TS), a neurological disorder characterized by motor and vocal tics, frequently coexists with OCD. This overlap, particularly in individuals with Tourettic OCD (TOCD), presents a proposed clinical phenotype in which compulsions are driven not by anxiety or fear, but by sensory discomfort or an urge for somatic relief.[2,3] TOCD is often misdiagnosed as classical OCD or TS, potentially contributing to suboptimal treatment outcomes due to its distinct sensory-driven nature.[4] While TOCD is not formally recognized in the Diagnostic and Statistical Manual of Mental Disorders-5 or the International Classification of Diseases-11, it represents an emerging phenotypic overlap between OCD and TS, warranting further investigation into its neurobiological and clinical distinctiveness. This case series aims to delineate the clinical features, comorbidities, and treatment responses of TOCD in children and adolescents, offering a conceptual model to guide its recognition and management as a distinct syndrome. METHODOLOGY This is a retrospective case series describing consecutive patients seen at the Child Guidance Clinic who met predefined inclusion criteria. Clinical data were extracted from patient records and supplemented with follow-up assessments where available. The case series employed a comprehensive approach to investigate the clinical manifestations, distinguishing features, and treatment outcomes of TOCD. Three patients presenting with symptoms consistent with TOCD were selected from the Child Guidance Clinic at St. John’s Medical College Hospital, Bengaluru. Inclusion criteria required the presence of both tic-like behaviors and obsessive–compulsive symptoms, evidence of sensory-driven compulsions or “just-right” phenomena (e.g., repetitive actions to alleviate sensory discomfort), and, where applicable, comorbid neurodevelopmental disorders. Patients were excluded if their symptoms were better explained by classical OCD (i.e., primarily anxiety-driven) or other psychiatric conditions without tic-related features. For this study, TOCD was defined as a proposed phenotype combining tic-like behaviors and obsessive–compulsive symptoms driven by sensory discomfort rather than anxiety, as described by Mansueto and Keuler.[3] Sensory-driven compulsions refer to repetitive behaviors motivated by a need to alleviate physical discomfort or sensory urges, while “just-right” phenomena describe actions performed to achieve a sense of sensory completion or relief, often without cognitive obsessions.[4] This case series was reported in accordance with CARE (Case Reports) guidelines. Data collection involved detailed clinical assessments for each patient, encompassing a thorough medical and developmental history, family history of neuropsychiatric disorders, and a comprehensive evaluation of symptom presentation and progression. Psychiatric and neurological examinations were conducted to assess the nature and severity of tics and obsessive–compulsive symptoms, the presence of sensory discomfort or “just-wrong” sensations, associated behavioral issues, and their impact on daily functioning and quality of life. Standardized assessment tools were utilized to quantify symptom severity, including the Yale Global Tic Severity Scale (YGTSS) for tic frequency, intensity, and impairment. The Children’s Yale-Brown Obsessive–Compulsive Scale (CY-BOCS) was used for obsessive–compulsive severity. Baseline scores were recorded at the initial evaluation, with follow-up assessments conducted to monitor treatment progress. Individualized treatment plans were developed based on each patient’s clinical profile, incorporating pharmacological interventions (e.g., selective serotonin reuptake inhibitors [SSRIs], antipsychotics, and alpha agonists), psychotherapeutic modalities (e.g., cognitive behavioral therapy [CBT] and habit reversal therapy [HRT]), and adjunctive therapies (e.g., sensory integration therapy and parent management training [PMT]). Treatment outcomes were evaluated using a combination of clinician-observed symptom reduction (e.g., changes in YGTSS and CY-BOCS scores), patient- or caregiver-reported improvements in sensory discomfort and compulsive behaviors, and functional improvements (e.g., school attendance and social engagement). Ethics approval The case series protocol was reviewed and approved by the Institutional Ethics Committee (IEC) of St. John’s Medical College, Bengaluru, prior to initiation (IEC No. 27/2025). Written informed consent was obtained from the parents, with assent obtained from the patients where developmentally appropriate. CASE SERIES Case 1 Background A 17-year-old female with delayed developmental milestones and a family history of bipolar disorder, anxiety, and OCD presented with a 5-year history of intrusive thoughts and compulsive behaviors (such as hoarding, checking, and ritualistic acts) along with a 4-year history of motor and vocal tics. Symptoms The patient exhibited pronounced sensory discomfort associated with incomplete compulsions and the fusion of tics with obsessional themes. For instance, intrusive thoughts such as “I must greet people to avoid being disrespectful” or “If I do not arrange my mother’s belongings, harm may come to her” were neutralized by repetitive greetings or ritualistic arranging until the “just-right feeling” was achieved. Sensory distress also precipitated her tics, such as throat clearing and facial movements, which were consistently linked to psychological triggers rather than occurring randomly. The fusion of tics with obsessional themes was evident as throat clearing and facial tics intensified during compulsive rituals, such as when arranging belongings, reflecting a seamless sensory-motor overlap. The discomfort was described as generalized discomfort “in my throat” and “on my face,” rather than anxiety. Treatment The patient was started on fluoxetine 20 mg/day, which was titrated to 80 mg/day over 4 weeks. The patient had six sessions of therapy which included CBT and HRT. Parental management training was also done twice a month for 3 months. This integrated approach addressed both tic-related and obsessive–compulsive phenomena. Outcome Tic severity decreased by 15 points on the YGTSS. Compulsive behaviors reduced by 60% based on patient-reported frequency and distress levels. The patient reported improved distress tolerance, fewer compulsions driven by sensory discomfort, and a reduced need for tic suppression strategies. Tourettic obsessive–compulsive disorder conceptualization: This case illustrates TOCD as a sensory-motor blend where repetitive behaviors (tics or compulsions) aim to alleviate internal discomfort rather than conforming to distinct diagnostic categories. Case 2 Background A 13-year-old male diagnosed with autism spectrum disorder (ASD), tic disorder, OCD, and speech delay presented with escalating repetitive behaviors and severe agitation triggered by environmental disruptions. Symptoms The patient exhibited compulsions such as ensuring that objects remained in fixed positions, experiencing pronounced distress and aggression (pinching and hitting) when routines were disrupted. He described pinching and hitting behaviors as responses to a “wrong sensation in the hand” and noted that these actions provided “relief in the hand.”The patient’s ASD-related sensory sensitivities likely amplified TOCD symptoms, as environmental disruptions triggered intense sensory overload, escalating both compulsive pinching and vocal stimming to restore comfort. This overlap exacerbated sensory overload, making environmental changes more likely to trigger compulsive behaviors and aggression compared to typical TOCD presentations. The patient did not report elaborate fears if the compulsions were not performed but found the sensations distressing. Symptoms intensified over a 1-month period, accompanied by sleep disturbances and school complaints. Upon examination, he exhibited restlessness with repetitive hand movements, vocal stimming (repeating phrases such as “How are you? God bless you”), and limited responsiveness to instructions. Treatment Management included fluoxetine (60 mg) for obsessive–compulsive symptoms, aripiprazole started at 2.5 mg and subsequently adjusted to 15 mg to manage tic severity, aggression concerns as well as impulsivity, in conjunction with occupational therapy, sensory integration therapy for hypersensitivity, and PMT for aggression. Outcome Following treatment, the patient demonstrated notable improvements across multiple domains. Aggression episodes decreased from 5 per day to 1 per week. School attendance improved from 50% to 85%, initially attending half a day in school for 3 months, then full day. Sleep disturbances resolved, with the patient sleeping through the night without frequent awakenings. These behaviours were triggered by distress during transitions or unmet demands, reflecting a sensory-driven need for completion rather than fear-based avoidance. Tourettic obsessive–compulsive disorder conceptualization Pinching and hitting were described as involuntary responses to sensory overload, distinct from anxiety-driven compulsions. This case reflects TOCD-like features driven by sensory discomfort (“just-wrong” sensations) rather than elaborated fears, blending characteristics of tic disorder, ASD, and OCD. Case 3 Background An 18-year-old female with a history of TS, OCD, attention-deficit/hyperactivity disorder (ADHD), and mild intellectual disability presented to the Child Guidance Clinic with a 4-month history of irritability, aggressive outbursts, and complex repetitive behaviors. Family history was notable for anxiety disorders in first-degree relatives. Symptoms The patient exhibited a range of challenging behaviors, including irritability, aggressive outbursts (e.g., spitting, pinching, hitting, and throwing objects), and complex tics. These behaviors were triggered by unmet demands (e.g., insistence on specific routines) and during transitions, such as attending school or visiting crowded places like family gatherings. She also displayed repetitive compulsive behaviors, such as touching, kissing, and hugging family members, which she felt compelled to perform repeatedly until achieving a “just-right” sensation. She described this sensation as a need to “feel complete” rather than a response to specific fears or obsessions. Complex tics included lip movements (e.g., pursing and smacking), spitting (occurring in bursts of 3–5 episodes daily), and pulling at clothing, especially the corners of bed sheets and pillow covers. These tics were often preceded by sensory discomfort, described as “tightness in my mouth” or “something stuck in my hands,” rather than anxiety. Although symmetry and cleanliness concerns were explored during the evaluation, they were not prominent features. At baseline, her YGTSS score was 72/100, with significant impairment in daily functioning. Treatment The patient’s treatment plan was multimodal, designed to address tics, obsessive–compulsive symptoms, aggression, and underlying anxiety. She was started on sertraline at 50 mg daily, titrated to 100 mg over 4 weeks to target obsessive–compulsive symptoms, anxiety, and low self-esteem, alongside aripiprazole, initiated at 2.5 mg daily and increased to 5 mg after 2 weeks to manage aggression and tic-related impulsivity. Clonidine was prescribed at 100 µg daily to reduce tic severity and irritability. Behavioral management therapy was provided through weekly sessions focusing on identifying triggers (e.g., transitions and sensory overload) and teaching coping strategies to mitigate anxiety-driven behaviors, while eight sessions of PMT equipped caregivers with strategies to manage aggression, reinforce positive behaviors, and establish consistent routines. Treatment adjustments were made based on clinical response and tolerability, with regular follow-ups every 4 weeks. The patient’s mild intellectual disability necessitated simplified CBT and HRT protocols, with increased reliance on caregiver-guided sensory strategies to accommodate cognitive limitations. Outcome Over a 6-month treatment period, the patient showed significant improvement across multiple domains: tic severity decreased, with her YGTSS score dropping from 72 to 38 (a 47% reduction). Aggressive outbursts reduced from daily occurrences to 1–2 episodes per month. Compulsive behaviors, such as touching and kissing, decreased by approximately 50% in frequency, as reported by the patient and caregivers, paralleling the 47% reduction in tic severity. Functional improvements included better engagement in daily activities, such as attending school (attendance increased from 60% to 90%) and participating in family interactions without distress. Tourettic obsessive–compulsive disorder conceptualization: This case exemplifies the interplay between sensory-driven compulsions, complex tics, and psychological distress in TOCD. The patient’s repetitive behaviors (e.g., touching, kissing, and hugging) were motivated by a need to alleviate sensory discomfort and achieve a “just-right” sensation, rather than to neutralize anxiety or catastrophic thoughts, distinguishing TOCD from classical OCD. The exacerbation of tics and aggression during periods of distress highlights the sensory-motor and emotional overlap characteristic of TOCD. The significant response to a multimodal treatment approach, including sensory-focused behavioral strategies and tic-targeted pharmacotherapy, underscores the need for tailored interventions in this population. DISCUSSION Key findings from the case series The three cases demonstrated sensory-driven compulsions (e.g. ritualistic arranging, touching, and vocal stimming) motivated by “just-right” sensations rather than anxiety, distinguishing TOCD from classical OCD. Case 1 highlighted a seamless tic–compulsion fusion, with tics escalating during compulsive rituals. Case 2 illustrated how ASD amplified sensory triggers, intensifying compulsive aggression, while case 3 showed complex tics and compulsions exacerbated by distress, with intellectual disability complicating therapy delivery. All cases responded to multimodal treatments (SSRIs, antipsychotics, and sensory-focused therapies), achieving 47%–60% reductions in tic and compulsive behaviors, suggesting tailored interventions are critical. Table 1 highlights the variability in comorbidities and symptom presentation, with convergence in sensory-driven compulsions and multimodal treatment efficacy.Table 1: Cross-case comparison of Tourettic obsessive-compulsive disorder features in the three casesDiagnostic challenges in Tourettic obsessive–compulsive disorder Differentiating TOCD from classical OCD and TS posed challenges in all three cases, as sensory-driven compulsions overlapped with tic-like behaviors. Clinicians relied on the absence of anxiety-driven obsessions and the presence of “just-right” sensations (e.g. case 1’s need for ritualistic arranging to achieve sensory relief and case 3’s touching to “feel complete”) to identify TOCD, as opposed to fear-based motivations typical in OCD.[5] The fusion of tics and compulsions (e.g., case 1’s escalated throat clearing during rituals) and sensory triggers (e.g., case 2’s hand discomfort) were critical heuristics, underscoring the need for careful phenomenological assessment to guide accurate diagnosis and tailored treatment. Distinctive clinical characteristics As shown in Table 2, TOCD combines sensory-driven behaviors from TS with complex compulsions resembling OCD.Table 2: Comparison of clinical features across Tourette’s syndrome, classic obsessive–compulsive disorder, and Tourette obsessive–compulsive disorder in children and adolescentsSensory-driven phenomenology In contrast to classical OCD, which is typically characterized by fear-based obsessions and anxiety-neutralizing compulsions, TOCD is primarily distinguished by sensory discomfort and a compelling need for somatic relief. Individuals with this condition frequently report sensations such as “wrong feelings,” “incompleteness,” or localized tensions that necessitate resolution through repetitive behaviors as outlined in all the three cases. These behaviors, which may encompass ritualistic arranging, symmetry-focused actions, motor tics, vocal stimming, and even aggressive responses to sensory disruptions, aim to alleviate internal discomfort and achieve a “just-right” psychological state. This sensory-motor mechanism diverges significantly from the traditional anxiety-based model of OCD. Analogous concepts, such as cognitive tics, sensory-based rituals, and acts of sensory fulfillment, have been documented in previous studies, corroborating the unique sensory-driven nature of TOCD. Comorbidity and neurodevelopmental complexity The cases reviewed demonstrate the frequent association of TOCD with neurodevelopmental conditions. Patients commonly present with additional diagnoses, including ASD, TS, and ADHD. This pattern suggests a broader neurological substrate underlying the symptoms of TOCD. Dysregulation in the corticostriatal-thalamo-cortical pathway may underlie the overlap of TOCD with ASD and ADHD.[6] The intersection of sensory processing difficulties, motor regulation issues, and psychological distress in these cases underscores the necessity for a nuanced understanding of the condition. Addressing sensory hypersensitivity and distress-driven compulsions is crucial for effective management. Treatment challenges and opportunities Treatment outcomes in the case series All three cases responded well to multimodal treatments combining SSRIs, antipsychotics, and sensory-focused therapies [Table 1]. However, SSRIs alone (e.g. fluoxetine in case 1 and sertraline in case 3) showed partial efficacy, requiring adjunctive antipsychotics (aripiprazole) or alpha agonists (clonidine in case 3) to address tics and aggression. Standard Exposure and Response Prevention (ERP) was less effective due to the sensory-driven nature of compulsions, necessitating adaptations such as sensory integration therapy (case 2) and simplified CBT for intellectual disability (case 3). These findings highlight the need for personalized, sensory-focused interventions over traditional anxiety-based approaches. Limitations of standard obsessive–compulsive disorder treatments Conventional treatments for OCD, such as SSRIs and ERP, frequently demonstrate limited efficacy for patients with TOCD. This limitation can be attributed to the distinct etiology of the condition, which primarily involves sensory discomfort rather than anxiety-driven compulsions. ERP targets anxiety-driven compulsions, whereas TOCD behaviors are motivated by sensory relief, necessitating sensory-focused interventions. Effective management strategies for TOCD may necessitate a multimodal approach that addresses the distinct sensory and motor components of the disorder. Interventions may encompass: Sensory-focused therapies: Techniques designed to mitigate sensory hypersensitivity Cognitive-behavioral strategies: Methods that specifically target discomfort-driven compulsions rather than anxiety Pharmacological interventions: Medications targeting tics, such as antipsychotics or alpha agonists, may prove efficacious. Potential for early and targeted interventions The recognition of TOCD as a distinct syndrome facilitates earlier and more targeted interventions. Addressing the condition during childhood or adolescence may potentially prevent its progression into chronic adult OCD, thereby potentially improving long-term outcomes. Overlap with neurodevelopmental conditions TOCD exemplifies the intricate interrelationship between tic disorders and OCD within the broader spectrum of neurodevelopmental conditions. The high prevalence of comorbidity with ASD, ADHD, and TS suggests shared underlying mechanisms involving sensory processing and motor regulation dysfunctions. Further empirical investigation is necessary to elucidate the precise neurobiological and psychological pathways linking these conditions. Elucidating these relationships can inform more comprehensive and individualized therapeutic interventions. Historical indicators of Tourettic obsessive–compulsive disorder Early sensory hypersensitivity (e.g. aversion to certain textures or clothing)[3] Family or personal history of tics[3] Comorbidities such as ADHD, learning disorders, and impulse control issues[3] Atypical treatment responses, such as poor outcomes with SSRIs or and response (ERP) due to long-term management Early recognition of sensory-driven compulsions in patients with The need for tailored therapeutic combining tic and sensory integration in TOCD from classical OCD and other neuropsychiatric Limitations This case series on TOCD but limitations. The of three cases and the absence of a control the of outcomes. As the was based in a may have to of severe cases. follow-up data long-term to TOCD are in Table the by this case understanding and improving the management of TOCD. This case series highlights the complex sensory-driven compulsions and neurodevelopmental comorbidities in TOCD, distinguishing it from classical OCD The findings that TOCD represents a within the characterized by “just-right” phenomena and sensory-motor overlap, as seen in the 47%–60% symptom reductions with multimodal treatments across three cases. While these tailored assessment and sensory-focused therapeutic further empirical is to establish TOCD as a distinct sensory integration and tic management may outcomes in and data consent clinical Data of of or to or data of of tools of patient consent The that they have obtained all patient consent In the the patients have their consent for their and other clinical to be reported in the The patients that their and not be and due be made to their but be and of are of