Predictors of Early Adult Outcomes in Pediatric-Onset Obsessive-Compulsive Disorder

Abstract

OBJECTIVE

The aim of this study was to determine the childhood clinical predictors of early adult outcomes in pediatric-onset obsessive-compulsive disorder (OCD) and to assess whether dimensional subtypes of OCD and the presence of comorbid tic symptoms influence long-term outcomes.

METHODS

We conducted a longitudinal cohort study in which 45 of 62 eligible children with OCD were reassessed an average of 9 years later, in early adulthood. Main outcome measures included expert-rated, obsessive-compulsive (OC) symptom severity and time to remission of OC symptoms. Baseline clinical characteristics were evaluated in terms of their influence on OCD severity in adulthood and time to remission of OC symptoms.

RESULTS

Forty-four percent of subjects were determined to have subclinical OC symptoms at the follow-up evaluation. The absence of a comorbid tic disorder and the presence of prominent hoarding symptoms were associated with the persistence of OCD symptoms. Female gender, earlier age at childhood assessment, later age of OCD onset, more-severe childhood OCD symptoms, and comorbid oppositional defiant disorder also were associated with persistence of OCD symptoms into adulthood.

CONCLUSIONS

These results confirm that a significant proportion of treated children with OCD experience remission by adulthood. The presence of comorbid tics heralds a positive outcome, whereas primary hoarding symptoms are associated with persistent OCD.

The prevalence of obsessive-compulsive disorder (OCD) in epidemiological studies of pediatric populations ranges from 1% to 3%, a rate similar to that observed in adult populations. ^1–3 The majority of OCD cases in adulthood arise after the teenage years, which suggests that many of the pediatric-onset cases of OCD may remit by adulthood. A meta-analysis of previous follow-up studies of pediatric-onset OCD suggested that as many as 40% to 59% of cases remit.⁴ However, many of the studies included in the previous meta-analysis were conducted before the widespread use of effective, evidence-based treatments for OCD, such as selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy, and before the introduction of validated clinical rating scales for OCD. In addition, follow-up intervals in most of the studies ranged from 1 to 5 years; therefore, the studies had limited ability to assess adult outcomes. To our knowledge, no previous studies have assessed outcomes after a sufficient period to determine early adult outcomes in OCD.

Pediatric OCD has been hypothesized to be a distinct developmental subtype of OCD.⁵ In contrast to adult-onset OCD, pediatric OCD is associated with a distinct prepubertal age of onset, male predominance, strong family history of OCD, and high rate of comorbid tic disorders and attention-deficit/hyperactivity disorder (ADHD).⁵ In previous prospective longitudinal studies of pediatric-onset OCD, poorer long-term outcomes were associated with earlier age of OCD onset, increased duration of illness before treatment, inpatient hospitalization because of OCD, comorbid tic disorder, and poor initial response to pharmacologic treatment.^4,6

A recent meta-analysis of 21 factor-analysis studies involving >5000 subjects demonstrated a fairly robust 4-factor structure for OCD that was remarkably consistent across the lifespan.⁷ The 4 OCD factors were (1) symmetry factor, which contained symmetry obsessions and ordering, repeating, and counting compulsions; (2) forbidden thoughts factor, which contained aggression and sexual and religious obsessions; (3) cleaning factor, which contained contamination obsessions and cleaning compulsions; and (4) hoarding factor, which contained hoarding obsessions and compulsions. These OCD symptom dimensions have been associated with distinct patterns of comorbid psychiatric conditions, different patterns of heritability, and specific genetic polymorphisms, as well as distinct symptom-associated patterns of neural activity, as measured with functional MRI.^8–11 Symptom dimensions have been associated with different responses to pharmacologic and non-pharmacologic treatments.^12,13

The goals of this study were to determine childhood clinical predictors of early adult outcomes in pediatric-onset OCD and to determine whether specific obsessive-compulsive (OC) symptom dimensions are associated with outcomes of pediatric-onset OCD assessed in early adulthood. We specifically hypothesized that OCD symptom dimensions and comorbid tic disorders would be associated with persistence of OCD symptoms into early adulthood.

METHODS

Subjects

All participants were recruited through the Yale Tourette syndrome (TS)/OCD clinic. Eligible participants were required (1) to have a childhood diagnosis of OCD, (2) to participate in MRI or neuropsychological testing studies before 16 years of age (these were prerequisites for having a detailed clinical research evaluation at that time), and (3) to be >16 years of age at the time of the potential follow-up interview. Adulthood follow-up interviews took place, on average, 9 years after initial childhood evaluations. Exclusionary criteria in those earlier studies included a history of seizure, head trauma with loss of consciousness, ongoing or past substance abuse, or an IQ of <80. Parent written informed consent and subject assent were obtained at the childhood baseline assessment and subject informed consent at the follow-up evaluation. Compensation for participation was provided at both time points under the guidelines of the human investigations committee.

Of an eligible sample of 62 subjects evaluated at the baseline interview, 46 (74%) elected to participate. Reasons for nonparticipation included subject refusal to participate in a follow-up interview (n = 2) and inability to locate subjects (n = 14). At the follow-up interview, it was found that 1 participant had since been diagnosed as having Asperger disorder. He and his mother were reinterviewed by a trained psychiatrist, and it was determined that he likely had Asperger disorder rather than OCD in childhood; therefore, he was excluded from subsequent analyses because he was not representative of the population we were trying to study. Demographic data, as assessed at the childhood baseline interview, did not differ significantly between participants and nonparticipants, except for age at baseline evaluation (Table 1).

TABLE 1.

Demographic Comparison of Participants and Nonparticipants

	Participants	Nonparticipants
N	45	16
Age at evaluation, mean ± SD, ya	12.1 ± 2.0	9.9 ± 1.6
Male, n, %	34 (76)	12 (75)
TS, n, %	18 (40)	11 (69)
ADHD, n, %	18 (40)	6 (38)
Children’s Y-BOCS score, mean ± SD	11.6 ± 8.1	14.2 ± 9.8
Yale Global Tic Severity Scale score, mean ± SD	8.0 ± 10.8	14.2 ± 10.8

Participants differed significantly from nonparticipants only in having a significantly older age at baseline evaluation. This result is not surprising, given that the main reason for nonparticipation was our inability to locate subjects for follow-up assessment.

^aP < .001.

Interview Procedure at Childhood Baseline Assessment

Childhood baseline assessments occurred before 16 years of age and included current and worst-ever measures using the Children’s Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and Yale Global Tic Severity Scale.^14,15 The Schedule for Tourette and Other Behavioral Syndromes was used to survey other comorbid psychiatric illnesses. ¹⁶ Neuropsychiatric diagnoses were established through a best-estimate consensus procedure performed by 2 child psychiatrists after a review of all available materials.¹⁷ Available information typically included findings of a clinical interview performed by an attending physician in the TS/OCD clinic and a structured clinical interview performed by a trained research assistant. Participants were then classified, on the basis of these diagnoses, with respect to their diagnosis status (yes or no) for TS, chronic tic disorder (CTD), ADHD, major depressive disorder (depression), comorbid anxiety disorder besides OCD (anxiety), and oppositional defiant disorder (ODD). If a child received a diagnosis of social phobia, separation anxiety disorder, or generalized anxiety disorder, then he or she was considered to have a comorbid anxiety disorder. Participants and their families were also asked, at that time, about the age of onset of the OC symptoms.

Interview Procedure at Adulthood Follow-up Evaluation

Follow-up evaluations in early adulthood included current and worst-ever ratings on the Y-BOCS and Yale Global Tic Severity Scale.^14,18 Screening for comorbid psychiatric conditions was conducted with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders, and a standardized medication history was obtained.¹⁹ In addition, an interview with a parent or a close cohabitating adult was performed when possible, to verify symptom severity. We asked all subjects who had experienced significant improvement the age at which their OC symptoms remitted, which was defined in the interviews as the “the age your OC symptoms improved substantially.”

Data Analyses

All statistical analyses were performed with SAS 9.1 (SAS Institute, Cary, NC). Our primary outcome variable for analysis was the time from the initial childhood assessment to remission of OC symptoms. A participant was considered to have experienced remission if the Y-BOCS score at the follow-up evaluation was <8. A Y-BOCS score of <8 was chosen as our criterion for remission because a score of 8 differentiates subclinical (Y-BOCS scores of 0 –7) from clinical (Y-BOCS scores of ≥8) OCD symptoms.¹⁷ The age of OCD remission was determined through patient self-report at the follow-up evaluation. Time to remission was calculated by subtracting the age of the baseline childhood assessment from the age of remission.

The Kaplan-Meier method (implemented with SAS Proc Lifetest) was used to plot the overall survival function of our data and to test whether our a priori childhood clinical variables influenced the overall survival curve. Subject data were stratified according to comorbid CTD and primary OCD symptom dimension (symmetry, cleaning, forbidden thoughts, or hoarding). The Wilcoxon test was used to compare survival curves, because this method places greater weight on the time points that have more observations. A strict Bonferroni correction was used to set our threshold for statistical significance at P < .025.

We then used the Cox proportional-hazard model of survival analysis (Proc Phreg command in SAS) to construct the best-fitting exploratory model for our data. In our model, we examined the following variables of interest: age of onset, OCD severity at baseline childhood assessment, age at baseline assessment, depression, anxiety, TS, CTD, ADHD, conduct disorder, ODD, gender, and worst-ever OCD severity. Our best-fitting model was built by using the following steps: (1) we identified all variables that were significantly associated with time to OCD remission in univariate analyses; (2) all significant univariate terms were entered into the same model, individual terms were identified on the basis of the least significant P value, and then terms were removed if they did not improve the fit of the model significantly, according to the log-likelihood test; and (3) all nonsignificant univariate predictors of time to remission were added back into the model, and they were kept if they improved the fit of the model, according to the log-likelihood test (with a threshold of P < .05). We then added the dimensional measures of OCD to the best-fitting model with traditional clinical data, to determine whether this approach improved the fit of the model. We measured dimensional OC symptoms as follows: (1) factor scores for OCD dimensions were computed in a previously published study,²⁰ (2) OC symptoms in each dimension were rated as absent, present, or severe, and (3) participants were categorized as primarily having hoarding symptoms or not. These dimensional approaches were included in our final best-fitting model only if they improved the goodness of fit, according to the log-likelihood test.

In posthoc analysis, we compared baseline characteristics of subjects classified as remitters versus nonremitters in adulthood follow-up evaluations. All continuous variables were examined by using Student’s t test, and categorical variables were examined by using Fisher’s exact test.

RESULTS

Interview Times

Childhood baseline interviews took place at an average age of 12.1 ± 2.0 years (range: 8.0 –15.8 years). The average age for early adulthood follow-up evaluations was 21.1 ± 3.1 years (range: 16.0 –27.0 years). The average period between the initial and follow-up interviews was 9.0 ± 2.9 years.

Clinical Course of OC Symptoms

The average age of onset of OC symptoms was 8.0 ± 2.5 years (range: 4 –13 years). The average Y-BOCS score at the follow-up evaluation was 10.2 ± 8.6, compared with 25.6 ± 7.1 at the worst-ever assessment (age: 11.3 ± 2.4 years). Twenty subjects (44%) had minimal OC symptoms at the follow-up evaluation and were classified as having experienced remission (Children’s Y-BOCS scores of <8) (Table 2). Fourteen subjects (31%) had mild OC symptoms (Y-BOCS scores of 8 –15) at the follow-up evaluation, whereas 6 subjects (13%) had moderate OC symptoms (Y-BOCS scores of 16 –23) and 5 subjects (11%) had severe OC symptoms (Y-BOCS scores of 24–40).

TABLE 2.

Characteristics of Subjects With Remitted Versus Nonremitted OCD

	Remitted (N = 20)	Nonremitted (N = 24)
Demographic characteristics
Age, mean ± SD, y	12.1 ± 2.1	12.1 ± 2.1
Male, n (%)a	18 (90)	16 (67)
Age of onset, mean ± SD, y	7.6 ± 2.5	8.4 ± 2.6
Symptoms
Duration of symptoms, mean ± SD, y	4.5 ± 2.1	3.7 ± 3.5
OCD severity score, mean ± SD
Childhood assessmentb	8.4 ± 4.7	14.3 ± 9.4
Worst-ever childhood evaluationa	23.7 ± 8.4	27.8 ± 6.0
Comorbid conditions in childhood, n (%)
TS	10 (50)	7 (29)
CTDb	16 (80)	10 (42)
ADHD	10 (50)	8 (33)
Depression	6 (30)	7 (29)
ODD	6 (30)	7 (29)
Comorbid conditions in adulthood, n (%)
Depression	4 (20)	9 (38)
Bipolar disorder	0 (0)	3 (13)
Psychotic disorder	0 (0)	1 (4)
Alcohol abuse/dependence	5 (25)	5 (21)
Substance abuse/dependence	7 (35)	7 (29)
Body dysmorphic disorder	0 (0)	2 (8)
Primary OCD symptom dimension
Cleaning	7 (35)	5 (21)
Forbidden thoughts	6 (30)	5 (21)
Symmetry	6 (30)	5 (21)
Hoardingb	1 (5)	9 (38)
Treatment, n (%)
Childhood baseline assessment
Cognitive behavioral therapy	10 (50)	11 (46)
SSRIs	19 (95)	22 (92)
Antipsychotic agents	11 (55)	12 (50)
α2-Adrenergic receptor agonists	7 (35)	6 (25)
Adulthood follow-up assessment
SSRIs	11 (55)	16 (67)
Antipsychotic agents	3 (15)	4 (17)
α2-Adrenergic receptor agonists	1 (5)	1 (4)

Subjects with pediatric-onset OCD whose OC symptoms remitted in adulthood were more likely to have primary hoarding symptoms and less likely to have comorbid CTDs, compared with nonremitters.

^aP < .1.

^bP < .05.

Comorbid Conditions and Medication Use at Follow-up Evaluation

At the follow-up evaluation, 13 subjects (29%) had a history of major depressive disorder, and 2 (4%) met criteria for current major depression. One subject was diagnosed as having a psychotic disorder and another as having bipolar disorder during the follow-up interval. No subjects had bipolar disorder or psychotic symptoms at the childhood assessment.

At the baseline childhood evaluation, 41 subjects (89%) were taking SSRIs. At the follow-up evaluation, 27 (60%) patients continued to take SSRIs, whereas 14 patients (31%) had stopped using them. Only 4 participants (9%) had never used SSRIs. Two subjects (4%) were using α₂- adrenergic receptor agonists at the adulthood follow-up evaluation, compared with 9 (20%) at the childhood baseline evaluation. Seven subjects (15%) were taking antipsychotic medications at the adulthood follow-up evaluation, compared with 22 subjects (48%) at the childhood evaluation. Subjects with remitted versus nonremitted OCD did not differ significantly in medication use at the baseline childhood evaluation or adulthood follow-up evaluation.

Kaplan-Meier Model for a Priori Predictors of Time to OCD Remission

Kaplan-Meier survival plots demonstrated reduced time to remission of OC symptoms for subjects with comorbid tic disorders ( ${\chi }_1^2=6.0$; P = .02) (Fig 1). Primary OCD symptom dimension also was associated with the likelihood of remission at trend levels ( ${\chi }_3^2=6.6$; P = .09) (Fig 2). This result seemed to be attributable primarily to a significantly decreased likelihood of remission for individuals with primary hoarding symptoms, compared with other children with OCD ( ${\chi }_1^2=5.4$; P = .02).

FIGURE 1.

Survival curves comparing patients with OCD with and without comorbid CTD (red curve indicates patients with comorbid CTD; black curve, patients without CTD; circles, censored observations). Proportions of patients with OCD who experienced remission are indicated on the y-axis, and time since childhood baseline assessment is displayed on the x-axis. Patients with OCD with comorbid CTD experienced decreased time to remission of OC symptoms ( ${\chi }_1^2=6.0$; P = .02).

FIGURE 2.

Survival curves comparing patients with OCD according to primary symptom dimension (red curve indicates symmetry; green curve, cleaning; black curve, forbidden thoughts; blue curve, hoarding; circles, censored observations). Proportions of patients with OCD who experienced remission are displayed on the y-axis, and time since childhood baseline assessment is displayed on the x-axis. OCD symptom dimensions were associated with differences in the likelihood of remission at trend levels ( ${\chi }_3^2=6.6$; P = .09). Primary hoarding symptoms were associated with a significantly decreased likelihood of remission ( ${\chi }_1^2=5.4$; P = .02), compared with nonhoarding OCD symptoms.

Cox Proportional-Hazard Model for Time to OCD Remission

Our best-fitting model, according to the likelihood ratio test, is depicted in Table 3. Female gender, absence of comorbid tic symptoms, more-severe initial OC symptoms, younger age at childhood assessment, older age of onset, comorbid ODD, and primary hoarding symptoms were associated with increased time to remission of OCD symptoms. Using patient factor scores for OCD symptom dimensions and classifying OCD severity in each dimension did not improve the overall fit of our model, compared with using the clinical variables alone (our best-fitting model without the primary hoarding symptom variable).

TABLE 3.

Cox Proportional-Hazard Model of Time to Remission of Pediatric-Onset OC Symptoms

Parameter	Hazard Ratio (95% Confidence Interval)	P
Gender	0.06 (0.02–0.15)	.002
Childhood Children’s Y-BOCS score	0.89 (0.85–0.94)	.018
Age at baseline assessment	2.00 (1.64–2.43)	<.001
CTD	4.50 (2.15–9.42)	.042
ODD	0.17 (0.08–0.35)	.014
Age of OCD onset	0.77 (0.70–0.84)	.004
Primary hoarding symptoms	0.09 (0.03–0.25)	.023

A lower hazard ratio indicates an increased time to remission of OC symptoms. Female gender, more-severe initial OC symptoms, younger age at initial assessment, later age of onset, comorbid ODD, absence of comorbid tic symptoms, and primary hoarding symptoms were associated with increased time to remission. Overall model fit statistics were as follows: likelihood ratio: ${\chi }_7^2=38.0$; P < .0001 (N = 45).

Comparison of Children With OCD Remission in Adulthood Versus No Remission

Table 2 compares the characteristics of children whose OC symptoms remitted during adulthood with the characteristics of children whose symptoms did not. Decreased OCD severity at childhood assessment, presence of a comorbid tic disorder, and absence of hoarding symptoms were associated with remission in adulthood. Male gender and decreased worst-ever childhood OCD severity were associated with OCD remission at trend levels.

DISCUSSION

Findings from this follow-up study of pediatric-onset OCD indicate that a significant proportion of treated children experience remission by early adulthood. The proportion of remitters in our study ranged from 44% (Y-BOCS scores of <8) to 58% (Y-BOCS scores of <10), depending on the criteria used for remission. These results are consistent with a meta-analysis of previous studies of shorter duration, which estimated rates of remission of 40% to 59%.⁴ In the present study, we were able to describe the life course of pediatric-onset OCD, in which children experience onset at ~8 years of age and experience their worst-ever symptoms just before initial treatment, at 11 years of age. These results are in striking contrast to long-term outcome studies with adults, in which rates of remission of OC symptoms according to such strict criteria are much lower.²¹

Children with OCD and comorbid CTD had a briefer time to remission of OCD symptoms, compared with subjects without comorbid tics. Sixty-two percent of subjects with pediatric-onset OCD and comorbid CTD experienced remission by adulthood, compared with 22% of those who did not have comorbid CTD (Table 2). Tics among patients with OCD were associated previously with comparable responses to cognitive behavioral therapy, poor short-term responses to sertraline treatment, ²² and improved responses to antipsychotic augmentation.¹² Comorbid tics in children may indicate a developmental trajectory of OCD symptoms that mirrors that of tics in children with both disorders. Tic symptoms typically reach their worst-ever severity between 10 and 12 years of age and then improve during the course of adolescence.^24,25 The developmental changes that are responsible for improving tics in children during adolescence also may help ameliorate comorbid OCD symptoms in these children.

Participants with primary hoarding symptoms seemed to have poorer long-term outcomes, compared with other children with OCD, with rates of remission of 10%, compared with 54% for children with other primary OC symptoms. Experts have suggested that the hoarding OC symptom dimension should be used as a specifier in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Indeed, a strong case can be made that compulsive hoarding in the absence of other OCD symptoms should be listed as a diagnostic entity separate from OCD.^26,27 Genome-wide association studies have found an area on chromosome 14 that suggests linkage with compulsive hoarding but not other OC symptoms.²⁸ Functional neuroimaging studies demonstrated distinct patterns of glucose metabolism and brain activation during symptom provocation paradigms when hoarding and nonhoarding patients with OCD were compared.²⁹ Anatomic imaging studies demonstrated gray matter differences when compulsive hoarders were compared with other patients with OCD.³⁰ Hoarding symptoms also have been associated with poor treatment responses. Short-term trials demonstrated poorer responses to cognitive-behavioral therapy and pharmacotherapy for patients with OCD with primary hoarding symptoms. ^12,31–35 In children with OCD, hoarding symptoms are associated with poor insight, magical thinking, ordering and arranging compulsions, and higher levels of anxiety, aggression, somatic complaints, and overall externalizing and internalizing symptoms.³⁶ These data all suggest that compulsive hoarders may have distinct psychopathologic features and diagnoses, compared with other individuals with OCD.

In multivariate, exploratory, survival analyses, we found an association of increased baseline OCD severity with longer time to remission. This association is not surprising, given that we used Y-BOCS scores of <8 as our criterion for remission. Individuals with more-severe OCD would need a greater degree of improvement to achieve this metric. In addition, we found that a later age of onset and younger age at evaluation were associated with increased time to remission. This finding is in contrast to previous long-term outcome studies associating early age of onset and longer illness duration with poorer outcomes in univariate analyses.^4,6 The longer follow-up period, the larger proportion of children with comorbid tic disorders, and the use of multivariate analysis in our study may explain this difference. The association of decreased duration of treatment before assessment with greater persistence of OC symptoms suggests that greater acuity of onset of OC symptoms in children may portend poor outcomes. Another possible explanation is that unknown family and child factors could produce both greater treatment-seeking and poorer long-term prognoses. In our best-fitting model, comorbid ODD was associated with poor outcomes. Previous studies demonstrated that comorbid ODD is a predictor of poor responses to pharmacologic and behavioral therapies among children with OCD.^37,38

Our study has several important limitations. We achieved a 74% participation rate for all eligible participants in the follow-up portion of our study. Nonparticipants might have differed systematically from those who did participate. The only discernible difference between participants and nonparticipants at the follow-up evaluation, however, was the significantly older age at baseline assessment of participants, compared with nonparticipants. This finding was not surprising, because our inability to locate eligible participants was largely responsible for individuals not participating. Participant recall bias or measurement error in the recall of age at remission also is a possibility. Prospective studies with assessments at regular intervals are needed to confirm our findings. In addition, multiple clinical and dimensional variables were tested in the multivariate Cox survival models, which thus have a higher probability of type I error. Therefore, our findings in these models should be regarded as generating rather than confirming hypotheses. Participants were treated clinically with both pharmacologic and behavioral therapies throughout the follow-up period; therefore, our outcomes and predictor variables are indicative of the clinical course and not necessarily the natural history of pediatric-onset OCD.

Despite these limitations, this study provides data on early adult outcomes in a large cohort of children with OCD. It confirms the results of previous long-term outcome studies of pediatric-onset OCD in suggesting that long-term outcomes seem better than those for adults with OCD. We found that comorbid tic symptoms were associated with improved long-term outcomes in pediatric-onset OCD. Although comorbid tic symptoms have been associated with poor short-term responses to pharmacologic treatment in pediatric-onset OCD, tics may suggest a clinical course of OCD that is more likely to remit and that follows a developmental trajectory similar to that of tics. This study expands on previous results by suggesting that specific subtypes of OCD (particularly hoarding) may have worse outcomes than others, which emphasizes the importance of developing better behavioral and pharmacologic therapies for treating children with compulsive hoarding symptoms.

WHAT’S KNOWN ON THIS SUBJECT

Approximately one half of children with OCD experience remission of OCD symptoms with appropriate treatment.

WHAT THIS STUDY ADDS

Forty-four percent of children with OCD were not experiencing significant OCD symptoms at the follow-up evaluation in early adulthood. The presence of prominent hoarding symptoms and the absence of comorbid tic symptoms were associated with persistence of OCD symptoms.

ABBREVIATIONS

OCD

obsessive-compulsive disorder

TS

Tourette syndrome

ADHD

attention-deficit/hyperactivity disorder

Y-BOCS

Yale-Brown Obsessive Compulsive Scale

ODD

oppositional defiant disorder

SSRI

selective serotonin reuptake inhibitor

CTD

chronic tic disorder

OC

obsessive-compulsive