Co- occurring Conditions
Common Co Morbidities
Tourette's is a disorder in its own entity however a very high proportion of people living with Tourette's also have at least one other co-occurring condition.
Attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and Anxiety are the most common but not limited to co-morbidities that go with Tourette syndrome (TS).
ADHD
Symptoms can range from mild to challenging. Symptoms can be specific to certain environments like home or school.​
ADHD may include, difficulty sitting still, constant fidgeting, moving, talking, making noises, low patience threshold, for example, they may find it hard to wait in a queue or listen, this can also result in them interrupting others. They may also say and do things without thinking through the consequences due to their immature impulse regulations.Types of ADHD & some examples of their characteristics:Hyperactivity: noisy in play, fidgety, struggle to stay seated, always on the go, excessive talking.Impulsivity: difficulty waiting their turn, interrupts conversations, shouts out answers before the question is completed.Inattention: forgetful, poor organisation, distracted, loses things, appears to not listen, avoids tasks that require lots of attention, fails to complete tasks, makes careless mistakes.
OCD
Someone with OCD will experience recurrent obsessions and/or compulsions that are severe enough to affect everyday life. These obsessions are usually anxiety-driven. The symptoms of OCD are obsessions and compulsions. Obsessions are uncontrollable thoughts, images, impulses, worries, fears, or doubts. They are often intrusive (cause disruption and annoyance), unwanted, and can be frightening for the person experiencing them. People with OCD will often know that these thoughts are irrational, but this doesn’t mean they can control them.
The most common obsessional thoughts are worrying about the safety of others or worrying that everything needs to be arranged symmetrically so that it is ‘just right’.
Compulsions are purposeful behaviours and actions that are performed in an attempt to relieve the anxiety caused by obsessional thoughts. Often the behaviour is carried out according to certain rules or will be performed as a ritual.The relief provided by compulsions is only temporary and often reinforces the original obsession. Common compulsions include checking, counting, and touching.
OCD & Tourettes
It is thought that approximately one-third of individuals with TS experience recurrent obsessive-compulsive symptoms. (Khalifa and von Knorring 2005; Leckman et al. 1997)It can be difficult to tell the difference between a compulsion and a compulsive tic.
A compulsion is typically behaviour that is carried out in an attempt to relieve the anxiety that is caused by an intrusive or obsessional thought. A compulsive tic is more associated with a physical sensation and needs to be performed to relieve the urge sensation.
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The condition affects both children and adults and it is estimated that as many as 12 in every 1,000 people are affected by OCD in the UK.
TOURETTIC OCD
TOCD usually manifests as pure compulsions and rituals and does not have the fear element that something bad will happen if the ritual isn't completed.These rituals are preceded by a physical sensation rather than an anxiety-based thought.
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TOCD is rarer than OCD and the OCD treatment pathway CBT, is usually ineffective with TOCD.
The treatment pathway for TOCD is the same as Tic intervention. These conditions are separate conditions but they can look virtually the same. It's important to establish which 'version' you have as treatment options vary. In classic OCD an individual may experience intrusive thoughts and anxiety that precede a compulsion. You may feel that something bad may happen if the ritual/compulsion isn't completed. Ie: you or someone will come to harm.
The treatment pathway for OCD is Cognitive Behaviour Intervention (CBT) Both forms of OCD can be physically disabling and emotionally distressing, these rituals in both conditions can take hours, resulting in lateness to school, work, meetings, socialising, and even going to bed.For some individuals with TOCD these rituals cause them the most distress from their condition.
Anxiety
Anxiety is common in most children at some part of their childhood. Anxiety is an emotion that gives us an unpleasant feeling within our body.
Anxiety is often temporary in children and can vary during different times of their childhood.
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Anxiety is normal and a part of our survival skills, however, the level of these fears and anxieties are predetermined by our genes. Anxiety can also be learned by children watching parents who are anxious in certain situations. Anxiety can also be brought on by trauma.​Anxiety and Tourette syndrome are closely interlinked, they form a cycle. Anxiety of people with tics results in an increase of tics and increased tics results in an increase of anxiety and so on.
ADHD
ADHD is the most commonly co-occurring condition with Tourette Syndrome (TS) with around 20 – 30% of children with ADHD also having a tic disorder.
People with ADHD will have difficulty with paying attention, are much more energetic than others, and are unable to control certain impulses.
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ADHD is also diagnosed around the same age as TS and has a higher prevalence in boys.
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ADHD is caused by the movement and ‘braking’ systems in the individual's brain maturing more slowly.
As with TS, not every child with ADHD will carry their symptoms through to adulthood.
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Symptoms mostly start in childhood. The key thing to remember is that someone with ADHD is not behaving badly on purpose. The area in their brain which is responsible for self-control takes longer to mature than in children who don’t have ADHD.
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Types of Anxiety include:
Generalised Anxiety Disorder
Generalised anxiety disorder: Excessively worrying about a range of different things i.e. future, family, friends, or themselves, they may have difficulty in relaxing, they may also engage in challenging behaviour if expressing their feelings isn’t possible.
Separation Anxiety Disorder
Separation anxiety disorder: Children often go through this as a typical milestone, this anxiety appears when their parent leaves the room, but this usually stops around 30 months old. If it’s still present at school age it becomes a disorder.
Phobias
Phobias: An irrational fear of something specific, these emotions are extreme and very intense. Individuals may avoid certain situations that enhance this fear. Children may engage in challenging behaviour if they cannot communicate their fear.
Disinhibition
Medical term: Disinhibited behaviours are actions that seem tactless, rude, or even offensive.
They occur when people do not follow the usual social rules about what or where to say or do something.​ Disinhibition is the inconsistent ability to inhibit behaviours despite knowing they are inappropriate. Individuals experience movements, swearing, emotional outbursts, rage, infantile behaviours, noises, laughter, and so on. These can all be either contextual or not.​
Essentially, disinhibition is when it becomes extremely difficult to use learned inhibitory skills “in the moment”. It is important to know that these behaviours are part of Tourette Syndrome and they are not deliberate. Individuals with Tourette Syndrome are often unable to control their behaviour and can often appear to be overstepping the mark and impulsive.
Disinhibition
Disinhibition can impact all co-occurring conditions. OCD symptoms, sensory issues, tic urges, emotional regulation, and inappropriate language to name a few.​
Even though many individuals will know what they are doing or saying is inappropriate at the time, they are not able to restrict these behaviours.​Understanding disinhibition is essential in understanding Tourette’s!​Due to the inconsistency of these behaviours, the child may appear as being disrespectful, inappropriate, not “socially acceptable,” having emotional outbursts, showing silliness, having contextual swearing, or even rage. The disinhibition element of Tourette's can be a big problem within a school, I bet all of your children can tell you a time they have been "pulled" up on behaviour that wasn't necessarily a tic despite not having control over it. Disinhibited behaviour can place enormous strain on families and educators. It is also important to know that, just like Tourette’s, disinhibition can also be suggestible. So, reminders of behaviours are more likely to cause undesired behaviours.