Disrupted Cortico-Striato-Thalamo-Cortical Circuitry May Underlie Sleep Disturbances in the "Tourette Triad"

Obsessive-compulsive spectrum disorders (OCSDs), chronic tic disorders (CTDs), and attention-deficit/hyperactivity disorder (ADHD) frequently co-occur because of shared neurocircuitry and genetic relationships. Sleep difficulties are common within this "Tourette triad."

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Researchers now believe some sleep-related problems reflect disruptions in the cortico-striatal-thalamo-cortical (CSTC) pathway. Margaret D. Hall, a clinical psychology doctoral candidate at Miami University in Oxford, Ohio, Erica Greenberg, MD, director of the Pediatric Psychiatry OCD and Tic Disorders Program at Massachusetts General Hospital, and colleagues report in Harvard Review of Psychiatry.

Drawing on a Narrative Review

The authors searched PubMed, Google Scholar, PsychInfo, and Web of Science for relevant English-language papers published before August 2022. OCSDs were defined as obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), body-focused repetitive behavior (BFRB) disorders, and hoarding disorder. Chronic tic disorders were defined as Tourette syndrome and chronic/persistent motor or vocal tic disorder.

42 articles were selected: 23 on OCSDs, eight on CTDs, 10 on ADHD, and one on both CTDs and ADHD. The authors refer to these disorders collectively as CSTC-conditions.

Disordered Sleep May Be Intrinsic to CSTC-Conditions

The researchers found objective documentation of sleep movement disorders in adults with CTDs or OCD, and similar subjective findings were available for children with OCD, ADHD, or CTDs. In the few studies that included polysomnographic data, sleep disturbance patterns were noted in OCD, BFRB disorders, and CTDs. Subjective sleep latency problems and objective sleep spindle disruption were common.

There was consistent evidence that CSTC pathway disruptions that are associated with OCSDs, CTDs, and ADHD are shared with sleep disorders as well, implicating dysregulation of dopamine and GABA—primary neurotransmitters in CSTC circuitry.

The review findings support a bidirectional, additive relationship between sleep symptoms and CSTC-condition symptoms. Poor sleep seems to impair functional connectivity in the fronto-striatal circuitry, which probably exacerbate CSTC-condition symptoms. A better understanding of these changes could lead to more effective treatments.

Treatment May Need to Be Individualized

There are three potential approaches to treating sleep disturbances in patients with CSTC-conditions: treat the condition, which may indirectly treat sleep-related concerns; treat sleep-related complaints, which may indirectly treat symptoms of the CSTC-condition; or do both simultaneously. The most effective strategy may differ from patient to patient, depending on the specific condition(s) and sleep problems.

Careful treatment selection is particularly important for children taking medication for CSTC-conditions. Clinicians must weigh the potential long-term effects of altered sleep architecture against the substantial risks of untreated psychopathology.

For example, selective serotonin reuptake inhibitors (SSRIs), the first-line treatment for OCD and BDD, delay the onset of rapid eye movement (REM) sleep and decrease the proportion of time spent in REM sleep. It will be important to determine:

• Whether the benefits of an SSRI in treating OCD or BDD symptoms are moderated by its impact on sleep architecture
• Whether the adverse effects of an SSRI on REM sleep are caused solely by the SSRI or can emerge independently and secondary to the CSTC-condition itself

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