Tourettic OCD: A concept we can swear by?

An exploration of Tourettic OCD, an emerging clinical concept at the intersection of Tourette’s disorder and obsessive-compulsive disorder

In Kirk Jones’ critically acclaimed film I Swear, Robert Aramayo plays John Davidson, a Scottish activist with Tourette’s disorder (TD).¹ Set initially in the 1980s – a time when the condition received little public attention – the film opens with a 12-year-old Davidson spitting and swearing uncontrollably, being banned from the kitchen table at home, and being punished corporeally at school. In one scene, we see Davidson compulsively licking a lamppost that does not look straight, for fear that something bad will happen. The film tenderly portrays the practical challenges and stigma faced by a young man with TD and captures its common co-occurrence with obsessive compulsive disorder (OCD). It premiered at the 2025 Toronto International Film Festival, received five nominations at the 79th British Academy Film Awards and won two, including Best Actor in a Leading Role for Aramayo.

Both TD and OCD are well-established diagnoses, classified as separate disorders in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5).² In recent decades, however, there has been increasing recognition of a distinct endophenotype, Tourettic OCD (TOCD), as a hybrid blend of OCD and TD symptoms.³ To understand the concept of TOCD, it is important to consider the clinical profiles of TD and OCD individually. From there, emerging research delineates TOCD as a unique diagnostic entity with a clinical profile and neurobiology distinct from TD or OCD alone.

Tourette’s disorder

TD is defined in the DSM-5 as a neurological disorder which manifests during childhood and is characterised by the presence of multiple motor and one or more vocal tics. These persist for at least a year, even if they wax and wane in frequency. In the DSM-5, TD and the less-formal tic disorders are classified as motor disorders within the broader category of neurodevelopmental disorders. Specifically, a tic is defined in the DSM-5 as “a sudden, rapid, recurrent, nonrhythmic motor movement, or vocalisation”.

Tics are typically preceded by uncomfortable somatic sensations, or ‘premonitory’ urges, which are relieved by engaging in the tic. They can be simple or complex. Motor tics can range from simple movements of relatively short duration such as facial grimacing, blinking, or head jerking (simple motor tics) to more elaborate sequences of movements of a longer duration, involving multiple muscle groups (complex motor tics). Similarly, vocal tics can range from brief sounds such as coughing, grunting, or barking (simple vocal tics) to utterances of full words or phrases (complex vocal tics). Examples of complex vocal tics also include echolalia (repetition of the last-heard word or phrase) and coprolalia (utterances of socially unacceptable phrases or obscenities). Coprolalia has become strongly associated with the public perception of TD; however, it occurs in only a minority of individuals. One study which examined the prevalence of coprolalia in 597 people with TD found that it occurred at some point in the lifetime of 19.3 per cent of males and 14.6 per cent of females.⁴ Overall, research suggests that one in 162 children have TD, although some may be undiagnosed.⁵

The management of TD calls for an individualised approach, while all patients and caregivers should be provided with psychoeducation. Treatment is guided by the severity of the tics, the degree of associated distress or impairment, and presence of comorbidities. Mild tics which do not cause distress or dysfunction do not warrant pharmacological or behavioural tic suppression and are usually best managed with a supportive approach. Where tics cause distress or significant functional impairment, habit reversal training with comprehensive behavioural intervention for tics (CBIT) is recommended. CBIT focuses on learning about tic triggers and identifying premonitory urges. If tics persist, pharmacological treatment can be considered. For individuals with comorbid attention-deficit hyperactivity disorder (ADHD), alpha-2-adrenergic agonists, such as guanfacine or clonidine, can be used to target both tics and ADHD. Individuals with comorbid OCD should receive cognitive behavioural therapy (CBT) with or without a selective serotonin reuptake inhibitor (SSRI). Antipsychotic agents, such as aripiprazole, risperidone or haloperidol, can be considered when the benefits of treatment outweigh the risks (such as extrapyramidal, hormonal, and metabolic adverse effects). Botulinum toxin injections to affected muscle groups may provide symptomatic relief.⁶

Obsessive compulsive disorder

According to the DSM-5, OCD requires the presence of obsessions, compulsions or both. Obsessions are the individual’s own recurrent thoughts, mental images or urges, that are persistent, intrusive, and unwanted such that the individual tries very hard to suppress or ignore them. Themes typically include sickness or infection due to germs or chemicals; fear one might have left the oven on or door unlocked; fear of accidentally harming someone; or the need for exact balance, symmetry or order. Compulsions, meanwhile, are repeated rituals such as cleaning, handwashing, counting, checking, praying, and repeating words silently. They might also include the avoidance of touching, for example, doorknobs or money. Compulsions are not pleasurable, but may provide temporary relief and are performed in an attempt to neutralise the anxiety associated with obsessions. Rigid rules are common and usually excessive relative to what they are designed to neutralise or prevent. Distress, time wastage (typically more than an hour per day), and interference with normal life are a given.

Although OCD is a clinical diagnosis, inventories such as the Yale-Brown Obsessive Compulsive Scale (YBOCS) or its paediatric equivalent CYBOCS are useful aids. Treatment for OCD is typically individualised and multimodal. It can include CBT that involves exposure and response prevention (ERP), pharmacotherapy with an SSRI, or a combined approach. The latter is likely to be more effective than psychotherapeutic or pharmacological interventions alone. If there is an inadequate response to initial treatment, options might include switching to an alternative SSRI or the tricyclic antidepressant clomipramine, or augmentation with an antipsychotic.⁷

Linking Tourette’s disorder and OCD

It is well-known that TD and OCD frequently co-occur. Indeed, DSM-5 OCD includes a specifier to indicate whether an individual has a history of tic disorder – thought to occur in up to 30 per cent of cases. Meanwhile, estimates of OCD among people with TD vary. According to the US Centres for Disease Control and Prevention, more than 33 per cent of people with TD also have OCD.⁸ Indeed, a multicentre study of 1,374 individuals with TD found that 50 per cent of them also met criteria for lifetime OCD.⁹

It has been postulated that TD and OCD share genetic and neurobiological underpinnings. The cortico-striato-thalamo-cortical (CSTC) pathway is implicated in both TD and OCD, although different neurocircuitry loops within the CSTC pathway are involved. Genome-wide association studies have suggested that TD and OCD share some of the same genetic influences, with overlaps in multiple susceptibility loci and candidate genes, although no single major gene has been implicated.¹⁰

Tourettic OCD

So, where does OCD fit into all this? TOCD was first proposed as a conceptual framework by Mansueto and Keuler in 2005.³ Since then, emerging literature has recognised TOCD as a distinct endophenotype. In TD, repetitive behaviours or actions (tics) provide relief from the somatic discomfort or distress referred to as premonitory urges. In OCD, repetitive behaviours or actions (compulsions) provide relief from anxious drives or obsessions. In clinical practice, however, patients may find it difficult to distinguish between the two. Mansueto and Keuler postulate that a hybrid blend of premonitory urges and anxious drives occurs in TOCD, negating the need to distinguish between them.³ Compared to OCD behaviours alone, repetitive TOCD behaviours are less commonly characterised by checking or cleaning and more often involve complex, repetitive actions such as touching, tapping, and rubbing, alongside a need for exactness or a ‘just-right’ sensation. Other distinctive features of TOCD include a male predominance and earlier age of onset, compared to OCD alone.¹¹

But TOCD does not exist as a distinct clinical entity within the DSM-5. While OCD does have a tic-related specifier, it has been argued that this fails to capture the unique blend of symptoms seen in TOCD. Indeed, a history of tics is not strictly necessary for TOCD and, conversely, TD and OCD may exist comorbidly without the constellation of symptoms seen in TOCD.

The management of TOCD requires a multimodal approach incorporating both pharmacological and psychological interventions. While OCD and TD are typically managed with different psychotherapeutic approaches – ERP for OCD and CBIT for TD – treatment of TOCD may require a more flexible approach which incorporates elements of ERP to address anxiety-driven compulsions and CBIT to target premonitory urges and tic-like behaviours. Pharmacological treatment should be guided by the predominant symptomatology. SSRIs remain first-line pharmacological treatment for OCD symptoms, although their efficacy may be attenuated in the presence of comorbid tics. Antipsychotics may be used to augment SSRIs in treatment-resistant OCD and may also reduce tic severity. Alpha-2-adrenergic agonists, such as clonidine and guanfacine, may reduce tic severity, but do not directly address OCD symptoms. It is worth noting, however, that evidence guiding the treatment of TOCD specifically remains limited, and current management is largely extrapolated from the separate treatment of OCD and tic disorders. As such, treatment should be individualised according to the relative contribution of obsessive-compulsive symptoms, tics, and premonitory sensory phenomena.

The management of TOCD requires a multimodal approach incorporating both pharmacological and psychological interventions

Conclusion

The literature has conceptualised TOCD as a distinct endophenotype that may warrant recognition as a distinct diagnostic entity. It is equally plausible, however, that TOCD exists on a continuum of clinical presentations between TD and OCD. The absence of a formally recognised diagnostic classification, and the scarcity of randomised control trials, limits our understanding of the condition and its optimal management. As such, we lack standardised treatment guidelines, and current management for TOCD incorporates elements of both OCD and TD treatments.

Due to the distressing nature of the condition and impact on an individual’s functioning, further research is required to better understand the phenomenology of TOCD and establish the most suitable therapeutic approach.

References

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8. US Centers for Disease Control and Prevention. Data and statistics on Tourette syndrome [Internet]. Atlanta (GA): CDC; 2026 Mar 27 [cited 2026 Sep 6]. Available at: https://www.cdc.gov/tourette-syndrome/data
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10. Chang SW. Tourettic OCD: Same same, but different? Curr Dev Disord Rep. 2025;12:32
11. Katz TC, Bui TH, Worhach J, Bogut G, Tomczak KK. Tourettic OCD: Current understanding and treatment challenges of a unique endophenotype. Front Psychiatry. 2022;13:929526