What is the recommended treatment for obsessive-compulsive disorder (OCD) with tic disorders?

Treatment of OCD with Comorbid Tic Disorders

For OCD patients with comorbid tic disorders, start with SSRIs (first-line for OCD) at maximum tolerated doses for 8-12 weeks, and if response is inadequate, augment with atypical antipsychotics—specifically risperidone or aripiprazole—which can simultaneously improve both obsessive-compulsive symptoms and tics. 1

First-Line Treatment Strategy

Initial Pharmacotherapy

• Begin with an SSRI as monotherapy for the OCD component, as SSRIs remain first-line treatment even in the presence of tics 1
• Use higher doses than typically prescribed for depression: fluoxetine 60-80 mg daily, sertraline up to 200 mg daily, or paroxetine 60 mg daily 1, 2, 3
• Allow at least 8-12 weeks at maximum tolerated dose before declaring treatment failure 1
• All SSRIs show similar efficacy for OCD, so selection should be based on side effect profile and drug interactions 1

Concurrent CBT

• Initiate cognitive-behavioral therapy with exposure and response prevention (ERP) as soon as feasible, with 10-20 sessions delivered in-person or via internet protocols 1
• CBT can be used as initial monotherapy if this is the patient's preference and trained clinicians are available 1

Augmentation for Inadequate Response

When to Augment

• Approximately 50% of OCD patients fail to respond adequately to first-line SSRI monotherapy 1
• The presence of comorbid tics specifically indicates consideration of antipsychotic augmentation when SSRI response is partial 1

Recommended Antipsychotic Augmentation

• Risperidone is the best-evidenced atypical antipsychotic for augmentation in OCD with tics, with demonstrated efficacy for both obsessive-compulsive symptoms and tic reduction 1, 4, 5
• Aripiprazole is the second-choice atypical antipsychotic, with promising data and lower risk for metabolic adverse effects 1, 5
• These agents work by modulating dopamine neurotransmission, which appears involved in tic-related OCD subtypes 4, 6

Alternative Augmentation Options

• Sulpiride (a benzamide antipsychotic) may be beneficial for the combination of obsessive-compulsive symptoms, tics, and anxious-depressive problems 4, 5
• Clomipramine augmentation can be considered but carries risk of drug-drug interactions and increased adverse effects when combined with SSRIs 1, 7

Treatment Algorithm

Step 1: SSRI Monotherapy

• Start fluoxetine 20 mg daily, increase to 60-80 mg daily over several weeks 1, 2
• OR sertraline 50 mg daily, increase to 200 mg daily 3
• Continue for minimum 8-12 weeks at maximum tolerated dose 1

Step 2: If Inadequate Response

• Add risperidone starting at low dose (0.5-1 mg daily) and titrate based on response and tolerability 4, 5
• OR add aripiprazole starting at 5 mg daily 5
• This combination addresses both OCD symptoms and tics simultaneously 1, 4

Step 3: If Still Inadequate Response

• Switch to different SSRI or trial of clomipramine 150-250 mg daily 1, 7
• Consider intensive CBT protocols if not already implemented 1
• Evaluate for glutamatergic augmentation (N-acetylcysteine, memantine) 1

Critical Monitoring Requirements

Metabolic Monitoring with Antipsychotics

• Monitor weight, glucose, and lipid parameters when using antipsychotic augmentation 8
• Assess for extrapyramidal symptoms and tardive dyskinesia risk 5

Treatment Duration

• Maintain successful treatment for minimum 12-24 months after achieving remission due to high relapse risk 1
• Consider monthly CBT booster sessions for 3-6 months after acute response 1

Important Clinical Considerations

Why Antipsychotics Work in Tic-Related OCD

• Both serotonin and dopamine systems appear involved in tic-related OCD subtypes 4, 6
• SSRIs may reduce stress sensitivity and emotional problems, improving self-regulatory abilities useful for tic suppression 4
• Antipsychotics directly target dopaminergic dysfunction underlying tics while also augmenting SSRI effects on obsessive-compulsive symptoms 4, 6

Common Pitfalls to Avoid

• Do not abandon SSRI therapy prematurely—improvement may not be evident until 4-5 weeks, with full effect delayed until 8-12 weeks 1, 2
• Do not use SSRI monotherapy as sole treatment when tics are severe—early antipsychotic augmentation is appropriate 1, 4
• Do not combine clomipramine with SSRIs without careful monitoring—this increases risk of seizures, arrhythmia, and serotonin syndrome 1

Predictors of Poor Response

• Long history of disorder, severe symptoms, and comorbidity with tics are associated with poorer SSRI response 9
• However, antipsychotic augmentation specifically addresses this treatment-resistant subtype 4, 6