CASE: Perfect breath
Mr. C, a 20-year-old college student, is diagnosed with obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), and tic disorder (TD). His obsessions consist of a persistent sense that he is not breathing “correctly” or “perfectly.” He compulsively holds his breath to “rush blood to my head” until “the pressure feels just right.” Mr. C says that his OCD has had longstanding, significant negative impact on his academic performance and capacity to engage in other activities. Tics have been present for years and manifest as coughing and throat-clearing. After multiple syncopal epi-sodes from breath-holding with Valsalva maneuver—some of which caused falls and head injury—Mr. C is admitted to a residential psychiatric unit specializing in treating OCD. At the time of his admission, his Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores1,2 are 23 total, 12 on the obsessions subscale, and 11 on the compulsions subscale, indicating moderate to severe illness. Cognitive-behavioral therapy (CBT) is offered, along with a combination of escitalopram, 60 mg/d, and quetiapine, 50 mg/d. Quetiapine is over-sedating at subtherapeutic doses and Mr. C’s compulsions worsen. He reports that “[it] took longer and longer to get the ‘just right’ feeling.’” Quetiapine is discontinued and risperidone, 0.5 mg/d, is started, which decreases the frequency of his tics. When he is discharged after a 36-day stay, Mr. C’s Y-BOCS scores are greatly improved at 13 total, 7 on the obsessions subscale, and 3 on the compulsions subscale.
Mr. C’s psychologist refers him to our outpatient clinic for continued psychiatric evaluation and treatment of his OCD, ADHD, and TD. At this time, he is prescribed escitalopram, 60 mg/d, and risperidone, 0.5 mg/d, along with CBT with his psychologist. We do not readminister the Y-BOCS at this time, but Mr. C reports that his OCD is “60% improved.” However, he describes prominent obsessive thoughts regarding his breathing similar to those he experienced before residential treatment. These obsessive thoughts arise in the context of specific environmental “triggers,” such as other people coughing or his own tics. The obsessions lead to compulsive urges to engage in breath-holding rituals. Mr. C experiences the thoughts and compulsions as deeply troubling and they consume 5 to 6 hours each day. Mr. C reports impaired concentration in class and during studying: “I can focus for 5 minutes, then not for 2 minutes, then for 3 minutes… I can never stay focused for more than a couple minutes,” before becoming distracted “by my OCD” or other environmental stimuli. We note on exam prominent breath-holding occurring several times per minute. Mr. C says his OCD has not impaired his ability to socialize.
Mr. C notes that he has been exposed to an array of CBT techniques, but he has difficulty using these techniques because his “mind wanders” or he lacks “motivation.” He admits he occasionally has taken a classmate’s ADHD medication (mixed amphetamine salts [MAS], dose unspecified) and found it improved his ability to focus on his academic work.
The authors’ observations
Researchers have established a relationship among OCD, ADHD, and TD across all combinations of comorbidity (OCD and ADHD,3 ADHD and TD,4 OCD and TD,5,6 and all 3 entities7). Data suggests a poorer prognosis for OCD when comorbid with either or both of these conditions.8 Researchers have raised concerns that psychostimulants could exacerbate or potentiate tic behaviors in patients with ADHD,9,10 although safe and effective use of these medications has been documented in controlled trials of patients with comorbid ADHD and tics.11-13 Furthermore, tic suppression has been reported with psychostimulants,14 as well as a differential effect of stimulants on motor vs vocal tics.15 Despite these data (Table 1),9-15 the FDA regards using psychostimulants in patients with TD as a contraindication,16 although clinicians often recognize that this practice may be unavoidable in some circumstances because of high comorbidity rates. Psychostimulants could exacerbate obsessions or compulsions in some patients because of their dopaminergic properties or through mitigation of the purported anti-obsessional properties of dopamine antagonists.17
Although there is evidence that the prevalence of prescribed psychostimulant abuse is low among ADHD patients,18 diversion of prescribed medication is a risk inherent in the use of these agents, particularly among college-age patients.19,20
Table 1
Evidence of effect of psychostimulants on tics
| Study/disorder(s) | Medication and study design | Relevant findings |
|---|---|---|
| Lipkin et al, 19949; ADHD without TD | Chart review (N = 122) to determine the incidence of tics or dyskinesias in children treated with stimulants | Approximately 9% of children developed tics or dyskinesias, which predominantly were transient, with <1% developing chronic tics or Tourette’s syndrome. Personal or family tic history and medication selection or dosage were not related to onset of tics or dyskinesias |
| Gadow et al, 199515; ADHD with TD | Methylphenidate variable dose, placebo-controlled, 2-week trials (N = 24) | All children’s ADHD symptoms improved. At a 0.1 mg/kg dose, motor tics observed in the classroom increased, but there were fewer vocal tics observed in the lunchroom |
| Castellanos et al, 199710; ADHD with Tourette’s syndrome | Methylphenidate, dextroamphetamine, variable-dose, double-blind, placebo-controlled, 9-week crossover (N = 20) | 3 patients had consistent worsening of tics while taking stimulants. Stimulants reduced hyperactivity rates compared with placebo (P = .03). Stimulants improved ADHD symptoms and had acceptable effects on tics. Methylphenidate was better tolerated than dextroamphetamine |
| Gadow et al, 199911; ADHD with TD | 34 methylphenidate-treated children, followed at 6-month intervals for 2 years | No evidence that frequency or severity of motor or vocal tics changed during maintenance therapy |
| Tourette Syndrome Study Group, 200213; ADHD with TD | Clonidine alone, methylphenidate alone, clonidine plus methylphenidate, or placebo | Worsening of tics was not reported in any group at a rate significantly higher than placebo. Tic severity was more reduced in the 2 clonidine groups than in the methylphenidate group |
| Lyon et al, 201014; ADHD with Tourette’s syndrome | Dexmethylphenidate, single-dose challenge. Ten patients with or without TSP | Acute dexmethylphenidate administration resulted in tic suppression but did not augment TSP |
| Gadow et al, 200712; ADHD with TD | Double-blind, placebo-controlled, 2-week trials each of 3 doses of methylphenidate and placebo (N = 71) | MPH-IR did not alter the overall severity of TD or OCD behaviors. Teacher ratings indicated that MPH-IR therapy decreased tic frequency and severity |
| ADHD: attention-deficit/hyperactivity disorder; MPH-IR: methylphenidate immediate release; OCD: obsessive-compulsive disorder; TD: tic disorder; TSP: tic suppression protocol | ||