Introduction
Tourette’s disorder in a complex neuropsychiatric disorder with unclear
etiology. The occurrence of other neurological as well as psychiatric
comorbidities can make the diagnosis of this condition and options of
psychotropic treatment complicated. While Tourette’s disorder is
characterized by chronic motor and vocal tics of duration greater than 1
year, the presence of other movement disorders as well as psychiatric
symptoms can confound the diagnosis. Accordingly treatment rendered may
not be effective, and sometimes may result in exacerbation of symptoms.
A 19-year-old white male presented at our clinic with a 6 year history
of symptoms. He was referred by his primary care physician, after
treatment by a pediatrician and subsequently a neurologist and
psychiatrist proved to be ineffective and resulted in a marked
exacerbation of his symptoms. He had dropped out of high school,
experienced significant social anxiety, and was unable to seek training
at a trade school or function within his family. The condition started
when he was approximately 13 years old with social anxiety, obsessive
thoughts and a compulsive tendency to check and recheck the locking
system at his parent’s residence. He was also noted to have a nervous
“cough”. As symptoms progressed, he was noted to get increasingly
anxious, moody and withdrawn and afraid to go to school due to peer
ridicule. He was reported to have “mood swings” which were reported to
be symptoms of “irritability” followed by episodes of dysphoria and
withdrawal. He also had complex obsessive thoughts and his compulsive
behaviors expanded to include multiple “doing, undoing “ rituals. In
addition his tendency to cough became more frequent and was accompanied
by “throat clearing” sounds. He also showed a peculiar tendency to
repetitively “nod his head”, which was thought to be part of his
obsessive-compulsive symptomatology.
Previous treatment tried with risperidone produced marked dysphoria and
no relief of symptoms. A subsequent trial of clonazepam produced
significant disinhibition in his mood and behavior. Subsequent trial of
fluoxetine, fluvoxamine and clomipramine produced no benefits. A trial
of methylphenidate was attempted with marked increase in his anxiety,
obsessive thoughts, ritualistic behaviors as well as irritability, also
making him briefly suicidal. An empirical of carbamazepine was then
attempted with no benefit.
Upon initial presentation in our clinic he was noted to be a 19 year old
Caucasian male who appeared his chronological age. His milestones of
development were noted to be normal. There was no family history of tic
disorders anxiety disorders or mood disorders
On examination he was noted to be in stable medical condition with
temperature 98 degrees F, pulse 86 per minute and regular, height and
weight at the 50th percentile for his age.
On examination he was noted to be a slender Caucasian male who appeared
his chronological age. There was no evidence of dysmorphia. He was
left-handed, alert, oriented to time place and person. His affect was
labile and his mood was anxious and dysphoric and congruent. His thought
processes were somewhat circular with obsessive concerns about his
mother. He described his obsessive concerns for his mother’s welfare and
his ability to reduce these concerns by performing his compulsive
rituals. His thought content was prominent for normal sexual fantasies.
There was no evidence of delusional thinking or auditory/ visual
hallucinations. He showed limited insight into his problem. He exhibited
poor self-esteem.
Motor tics were limited to a peculiar sharp downward jerking movement of
his head which occurred in spurts and seemed to self-correct with a
tapping movement of his fingers on the examination table. During
examination he made multiple throat clearing sounds as well as coughing
lightly. This made him very anxious. In addition, during the examination
he was compelled to get up a few times and reached for the office door,
touch it likely and then returned to the examination table .
Upon neurological examination, his cranial nerves I through XII were
noted to be normal. His reflexes were bilaterally symmetrical and muscle
tone and power was also noted to be bilaterally normal. His coordination
and gait was normal. His physical examination revealed no abnormalities.
His chest was clear, heart had regular rate and rhythm, S1 and S2 and
his abdomen was benign.
Lab tests included a CBC, CMP, TSH, liver function tests, thyroid
profile, serum copper and ceruloplasmin, vitamin B12, and D3 and a urine
drug screen. These were all normal. MRI scan of the brain was normal as
was an EEG. His presentation appeared to meet DSM-V diagnostic criteria
for Tourette’s disorder, and surprisingly also for cyclothymic disorder,
OCD , chronic motor vocal tic disorder.
In our office, his last trial of medications methylphenidate and
carbamazepine were discontinued. Upon return in one week he was
initiated on a trial of lithium which was gradually increased over the
course of 2 weeks to 1200 mg per day. Serum lithium level was noted to
be 0.9 mEq per liter. 3 weeks after initiation of lithium therapy ,there
was a marked decrease in his symptoms. His coughing and throat clearing
were extinguished along with significant reduction in his obsessions as
well as compulsive behavior. Over the course of the next 3 months his
anxiety and moodiness also dissipated to quite some degree. He was able
to return back to school and get a GED. He subsequently went on to
finish trade school, and seek gainful employment. He was followed for 3
years with regular serum lithium levels and monitoring of her thyroid
function, renal function as well as electrocardiogram. At last follow-up
he was noted to be quite stable.