Until the mid sixties of the past century Tourette’s syndrome was classified as a psychiatric disorder based on occasional stress-related exacerbation, voluntary inhibition, and the frequent changes in the site and nature of tics. Recently many organic factors have been identified, in particular a genetic susceptibility and partial response to pharmacological treatment.
Adult onset tic disorders represent an under recognised condition that is more common than generally declared.
A patient's story
The patient was 72 years old when she went to her GP after developing an unpleasant and painful rash around her eyes. She was diagnosed with shingles which passed in a few weeks without further problems. Then she began to exhibit impulsive voluntary movements, characterised by a tendency to bite inanimate objects including clothes, furniture and other items near to her, including her own fore-arms, causing bruising.
These compulsive-type behaviours were often accompanied by grunting noises or poorly formed words. There was also some hair-pulling. These episodes increased both in frequency and severity, until her GP referred her for a psychiatric opinion, and she was interviewed at her home address.
Her symptoms progressed from simple vocal tics (grunting) to more complex motor tics including biting herself, inanimate objects, or pulling her hair.
Initially, she seemed to have reasonable control over these compulsions, but as the disorder progressed, she found it increasingly difficult to resist her urges. Soon, she began throwing objects or striking out at her husband without provocation; and when asked why, would often reply “because I love you.” She often filled her mouth so much that chewing and swallowing became difficult. Despite having insight, she felt unable to prevent herself from acting on her impulses.
She had an enjoyable childhood, growing up with her parents and older brother in a working class background. Having left school, she worked at the local launderette for 28 years. She married at the age of 23 years. Her marriage was good and the couple lived at their current address for 30 years. She had two sons, with one having died three years earlier, following chronic terminal illness.
She reported no past psychiatric, forensic or drug-misuse history. Family history included her mother receiving ECT following a depressive illness.
She had gradually become increasingly socially isolated, especially since her shingles infection. Her GP had treated her recent anxiety symptoms with propranolol and low doses of diazepam, with limited response.
Physical examination, routine blood tests and an EEG was unremarkable. MRI head revealed prominent bilateral cerebral white matter high signal changes. CSF examination was negative for varicella zoster; Cell count, protein and glucose normal.
A neuropsychological assessment concluded that cognitive function had deteriorated markedly since her shingles infection, in that she had severe core deficits in attention with subsequent impact on immediate and delayed memory, visuo-spatial functioning and executive functions.
It appeared that there was brain damage following Herpes Zoster infection, with compulsive symptoms mimicing Tourette’s syndrome.
Her diazepam medication was reduced and stopped, being replaced with low dose haloperidol, which was gradually increased to 1mg three times a day. She was also engaged in a behavioural programme with the clinical psychologist, which has led to a decrease in her impulsive and compulsive behaviours.
Authors: Amjad Jumai’an, Juhi sharma, George Tadros