"Just Right" OCD

Obsessive-compulsive disorder (OCD) is a psychiatric disorder that involves both obsessions (recurrent, persistent, intrusive thoughts, images, or urges that cause anxiety or distress) and compulsions (repetitive behaviors or mental acts aimed at neutralizing or reducing anxiety or distress or preventing the feared outcome). 

Understanding Feared Outcomes

Obsessions are unwanted private events that typically result in not only anxiety regarding the persistence of the obsession itself but also a feared catastrophic outcome. Feared outcomes commonly involve anticipatory anxiety regarding themes, such as being responsible for harm to oneself or to others, or being defined as unethical, immoral, or imperfect.

For example, obsessions regarding dirt and contamination may result in an overwhelming fear that if the dirt and contamination aren't mitigated, one may become ill or unintentionally cause others to become ill. In the case of contamination, one might choose to engage in washing or cleaning compulsions to reduce the chances that illness will occur and drastically diminish the anxiety.

"Just Right OCD" Explained

There is, however, a subtype of OCD for which a feared outcome is not the driving force. This is often referred to as “just right OCD” or “Tourettic OCD (TOCD).”

In TOCD, there's no elaborate obsessional belief structure or feared outcome that drives these behaviors, but rather, intense somatic (physical) and/or psychological tension or discomfort, often described as something feeling incomplete or “not right.” Sometimes, the distress is heightened by a belief that unless the behavior is performed, the discomfort will be intolerable and/or infinite.

The behaviors are then carried out to relieve these uncomfortable sensations. Some have postulated that this sensory-driven OCD is tic-like in nature and may be more distinctly characterized by an overlap between OCD and tic disorder/Tourette’s syndrome (TS).

Expressing a Tic

Tics are sudden, rapid, repetitive, nonfunctional motor behaviors (motor tics) or vocalizations (phonic tics), which are often preceded by premonitory (warning) sensations. This buildup of tension is relieved by tic expression, much like scratching an itch.

Common motor tics include behaviors such as eye blinking, shoulder shrugging, and head jerking, while common phonic tics include throat clearing, sniffing, and grunting. Tics may also be complex in nature, involving a sequence of behaviors such as touching, gesturing, and repetition of words or phrases.

Tourette’s syndrome involves the presence of multiple motor tics and one or more phonic tic(s) during the course of the disorder. Although once thought to be completely involuntary, people frequently have some control over the temporary suppression of these behaviors.

A 2015 study of 1,374 people with TS found that 72% also met the criteria for OCD or attention deficit hyperactivity disorder (ADHD).

Also of note, people with OCD who've had a comorbid tic disorder differ phenomenologically in terms of their OCD symptom themes, comorbidity, course, and pattern of familial transmission from those with no history of tic disorder. According to the American Psychiatric Association, research has suggested a genetic relationship between OCD and TS as well as hypothesized a shared neurobiological underpinning.

The Difference Between Tics and OCD

From a clinical perspective, the distinction between OCD and tics can be challenging to determine. For example, a repeated touching behavior may be viewed as tic behavior because of its brief, non-purposeful nature.

However, this may be indistinguishable from OCD in that it may be seen as repetitive behavior carried out until it feels “right.” Such distinction, however, may be important for clinical decision-making.

Whereas the evidence-based treatments for OCD are cognitive behavioral therapy—particularly exposure and response prevention (EX/RP)—and selective serotonin reuptake inhibitors (SSRIs), the evidence-based treatments for tic disorders are cognitive behavioral therapy, specifically habit reversal training (also known as, cognitive behavioral intervention for tics [CBIT]), and neuroleptic and alpha-2 agonists.

So, considering it as a phenomenon existing in an overlap of these two disorders may not only draw attention to the need to comprehensively assess for all possible behaviors in the obsessive-compulsive spectrum, it may also make more treatment options available.

Psychotherapeutically, these symptoms are typically treated with EX/RP, as well as the practice of engaging in “just wrong” behavior. Added elements of HRT/CBIT, such as sensory-substitution strategies and diaphragmatic breathing, are also helpful in reducing localized tension.

Pharmacologically, these people may be more likely to benefit from low-dose neuroleptic or alpha-2 agonist augmentation of SSRIs than typical OCD presentations.