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УДК 616.89-008.447-02:616.83-008.6-056.7-071-085 https://doi.Org/10.26641/2307-0404.2019.2.170159
OBSESSIVE COMPULSIVE DISORDER IN AN ADULT PATIENT WITH GILLES DE LA TOURETTE SYNDROME AND EXPRESSED BEHAVIORAL DISORDERS (CLINICAL CASE)
SE «Dnipropetrovsk medical academy of Health Ministry of Ukraine» Department of Psychiatry of Postgraduated Faculty V. Vernadsky str., 9, Dnipro, 49044, Ukraine e-mail: 604@dsma.dp.ua
CNE «Dnipropetrovsk clinical psychiatric hospital of Dnipropetrovsk regional council» Bekhterev str., Dnipro, 49115, Ukraine e-mail: dkpl@i.ua
ДЗ «Днтропетровська медична академiя МОЗ Укра'ши»
кафедра ncuxiampiï ФПО
(зав. - д. мед. н., проф. Л.М. Юр 'ева)
вул. В. Вернадського, 9, Днтро, 49044, Украша
КП «Днтропетровська клiнiчна психiатрична лiкарня» ДОР»
(головн. лiкар - к. мед. н. Ю.М. Завалко)
вул. Бехтерева, 1, Днтро, 49115, Укра'та
Цитування: Медичт перспективы. 2019. Т. 24, № 2. С. 83-86 Cited: Medicniperspektivi. 2019;24(2):83-86
Key words: obsessive compulsive disorder, Gilles de la Tourette syndrome, behavioral disorders Ключовi слова: обсесивно-компульсивний розлад, синдром Жиль де ла Туретта, noeediHKoei порушення Ключевые слова: обсессивно-компульсивное расстройство, синдром Жиль де ла Туретта, поведенческие нарушения
Abstract. Obsessive compulsive disorder in an adult patient with Gilles de la Tourette syndrome and expressed behavioral disorders (clinical case). Yuryeva L., Shusterman T., Varshavskyi Ya., Malyshko V. The article describes the clinical case of obsessive-compulsive disorder in an adult patient with Gilles de la Tourette syndrome and severe behavioral disorders. The authors demonstrated the comorbidity of Gilles de la Tourette syndrome and obsessive-compulsive disorder. Obsessive thoughts and compulsive actions were diagnosed as the most frequent behavioral disorders in Tourette syndrome. It was indicated on gender as an additional sanctioning factor for the early onset of mental disorders. Obsessive-compulsive disorder in the patient was characterized by mixed obsessive thoughts and actions, had a protracted nature, with prolonged decompensations requiring treatment in a psychiatric hospital. Emotional instability, impulsivity, obsessions and compulsions affecting the social functioning of not only the patient himself, but also those around him, as well as pronounced behavioral disturbances led to social malajustment. When treating the patient, the doctors had to resort to a combination of typical neuroleptics with second-generation antipsychotics, mood stabilizers and antidepressants due to the poor response to pharmacotherapy. Comorbidity of mental disorders determined the complexity of therapeutic measures with the use of psychotherapeutic interventions, which made it possible to achieve an improvement in the mental state and avoid disability of the patient.
Реферат. Обсесивно-компульсивний розлад у дорослого пащента з синдромом Жиль де ла Туретта i вираженими поведшковими порушеннями (клМчний випадок). Юр'ева Л.М., Шустерман Т.Й., Варшавський Я.С., Малишко В.О. У статтi наведено опис клтчного випадку обсесивно-компульсивного розладу в дорослого пащента i3 синдромом Жиль де ла Туретта i вираженими поведшковими порушеннями. Авторами продемонстрована коморбiднiсть синдрому Жиль де ла Туретта й обсесивно-компульсивного розладу. Дiагностовано нав'язливi думки й компульсивнi дИ як найбшьш частi поведiнковi порушення при синдромi Туретта. Вiдзначено гендерну приналежнкть як додатковий санкцюнуючий фактор раннього початку психiчних порушень. Обсесивно-компульсивний розлад у пацiента характеризувався змiшаними обсесивними думками й дiями, мав затяжний характер, з тривалими декомпенсацiями, що вимагали л^вання в умовах психiатричного стацiонару. Емоцшна несттюсть, iмпульсивнiсть, обсесИ i компульсИ, що торкнулися соцiального функщонування не тшьки самого пацiента, але й оточуючих, а також виражет поведiнковi порушення призвели до соцiальноi дезадаптацИ. При л^ванш пацiента довелося вдатися до поеднання типових нейролептиюв з антипсихотичними препаратами другого поколтня, нормотимiками й антидепресантами
L. Yuryeva, T. Shusterman, Ya. Varshavskyi , V. Malyshko *
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через погану eidnoeidb на медикаментозну терапгю. Коморб1дтсть психгчних розлад1в визначила ком-плекснкть терапевтичних 3Qxodie з використанням психотерапевтичних втручань, яка дозволила досягти nолinшення психiчного стану й уникнути iнвалiдизацi'i хворого.
Obsessive compulsive disorder (OCD) is a common mental disorder characterized by obsessive thoughts, memories, movements and actions, as well as various pathological fears (phobias) that require some effort to deal with them and cause distress and deterioration of the patient's quality of life [3]. From 60 to 80% of sick children and adolescents, like adults with OCD, have comorbid mental disorders, the most common of which is Gilles de la Tourette syndrome (GTS) [1].
GTS is characterized by combined voice and multiple motor tics, as well as behavioral disorders. The most frequent behavioral disorders in Tourette syndrome are obsessive thoughts and compulsive actions. The frequency of their occurrence with this syndrome, according to a number of authors, varies from 28 to 62%. As a rule, obsessions arise later than motor and vocal tics (sometimes several years later), and usually break the social adaptation of the patient. At GTS attention disorders, emotional lability, impulsivity and aggressiveness are also often observed [2, 4].
In OCD, tics are diagnosed in 20-59% of children and in 6-9% of adolescents and adults. Similarly, 48% of adult patients with OCD with early manifestation have Tourette syndrome, compared with 10% of those who have a late manifestation of the disorder. Some authors even single out a separate taxon - «tics associated with OCD», characterized by a greater hereditary burden, the predominant distribution among men; early age of onset and poor response to therapeutic interventions [5].
This article describes the clinical case of OCD with mixed obsessional thoughts and actions in an adult patient with Tourette syndrome that led to social maladjustment.
Male patient, V.P.A., 23 years old, does not work, the participant of military operations. He was under inpatient treatment in CNE «Dnipropetrovsk clinical psychiatric hospital of Dnipropetrovsk regional council» (CNE «DCPH DRC») from 08 October 2017 to 08 December 2017 in the department #31.
Anamnesis: the patient was born in a medical family, mother died when the patient was 1 year old. He has a younger half-brother. He was brought up by his father and stepmother; in recent years he lived with his grandmother on his father's side. Early development met age standards. He attended kindergarten, went to school at the age of seven years, studied poorly, had a few friends. He graduated from the 9th grade of secondary school and technical
school, acquired a profession of builder, however, did not work in the specialty. He worked as a security guard, went to Poland «to work». From childhood he dreamed of working in law enforcement agencies, he read literature on military topics. He was fond of sports, joined a gym. Alcohol, drugs did not use. In childhood, he suffered from colds. Tuberculosis, sexually transmitted diseases, hepatitis the patient denies. No allergic reactions.
At the age of eight, he learned from his grandmother that he was being raised by a stepmother, and his own mother had died. Six months after that, tics of lower limbs, nodding of the head, as well as vocal phenomena (guttural sounds, cries) appeared. The patient was treated in a neurological hospital and diagnosed with GTS. He took haloperidol, pantocalcin. By the age of eleven, tic symptoms smoothed.
From October 2012 to October 2013 he served in the presidential regiment. At first he was very proud of this, perceived service as romance. However, six months after the start of the service, he began to clash with the commanding staff, showed aggression attacks, obsessively demanded that his colleagues repeat some or other words. For non-compliance with the requirements of the statute, commanders wanted him to invalid out of the army, but he continued to serve until the end of the term. After serving in the army, he arranged for different jobs, but, due to conflicts, inadequate response to comments, he quit after 1-2 months. From 05 June 2014 to 26 June 2015 he voluntarily performed military service duties in the anti-terrorist operation; the patient has a certificate of a combatant. In 2014, while serving in the anti-terrorist operation, he received a craniocerebral injury (a blow to the parietal region with a pistol grip), did not lose consciousness, did not seek medical help. During the service he was irritable, hot-tempered, however, there were no significant conflicts with superiors and colleagues. Obsessive demands for co-workers to repeat his words were preserved, but were regarded by others as self-indulgence.
After returning home, relations with his father and stepmother deteriorated, he was extremely irritable, aggressive, and insistently demanded that they repeat certain words. In connection with the deterioration of the mental state, from 01 February 2017 to 22 February 2017, for the first time he was under inpatient treatment at CNE «DCPH DRC». The patient complained of headaches, depression,
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anxiety, obsessive thoughts and movements. In the department, many times he demanded from the staff and other patients to repeat questions and answers like «yes» or «no». He was discharged with a diagnosis of adaptation disorder with a mixed disturbance of emotions and behaviour at anancastic personality. After discharge, obsessive phenomena persisted. On 18 April 2017, after another confrontation with his father, his condition worsened, compulsive actions sharply increased, over six hours in a row he forced his grandmother in the kitchen to repeat different words and look at him. Brother filmed his strange behaviour on video and at the same time called the police. The police talked to him and left. In a state of anxiety, the patient impulsively collected his belongings and left for Poland, where he worked as an employee on construction sites. Obsessive thoughts and actions persisted, leading to conflicts at work. On 07 July 2017, in the store, from a stranger woman, began to demand that she repeat his words. The police were called and the patient was taken to a psychiatric clinic, where he stayed until 03 August 2017. It is known from the extract that he was agitated in the department, shouted, repeated the same phrase many times, the patient demanded that a nurse look at him. He remained irritable, tried to strangle other patients, became immobilized at times, which he explained the need to perform certain actions. The mood was unstable, the behaviour was impulsive. The patient was discharged with a diagnosis of bipolar disorder, mixed episode. He was recommended to take medication (lithium and aripiprazole). He decided to go back home, took two pills of donormyl in the train. Upon arrival home, he was extremely anxious, stated that he had «something with eyesight», «decreased visual acuity, dull», associated it with taking sleeping pills. He was restless constantly going out and entering the apartment. 08 September 2017, he was consulted by an oculist in a private clinic, conclusion: retinal angiopathy of the hypertonic type, latent hyperopia in both eyes, periodic concurrent divergent strabismus of the right eye. Visual gymnastics and consultation of a specialist in connection with sleep disorders and the need to take sleeping pills were recommended. In connection with the changed mental state, the patient was taken by father to CNE «DCPH DRC», the patient was hospitalized for treatment after receiving informed consent.
On admission: the patient was anxious, tense, withheld places with difficulty. Speech was as a monologue. Productive psychosymptomatics was not identified. He constantly asked: «I'll be fine, help me?». Somato-neurological disorders were not detected.
In the department: the patient was tense, anxious, restless. Constantly asked the same question: «Will everything be okay with my eyes?». He gave detailed anamnestic information, spoke in detail about obsessive thoughts and movements, about his «complex» character. In the process of treatment, obsessive worries about deteriorated vision decreased gradually, he became calmer, the behavior was formally ordered. However, the stereotypical asking of the same questions to medical personnel and other patients remained. Later he began to dissimulate the presence of obsessions. According to the staff and other patients, he continued to ask different questions and then insistently demanded that others repeat different words. When receiving a refusal to comply with his requirements, he became irritable, angry, demanded to look him straight in the eyes, and began to make obssessive movements with his foot. In connection with the violation of social adaptation, the patient was asked to undergo a Social Security Disability Medical Exam to resolve social issues, but the patient and his relatives refused.
Analyses: clinical blood and urine analysis -normal. Wasserman reaction (08 November 2017) was negative. Smear on diphtheria (08 October 2017) - diphtheria bacillus were not identified. Photofluorogram (08 August 2017) - the lungs and heart were normal.
Psychologist's conclusion: the slight violation of the operational, motivational components of thinking in the form of accelerating the associative process, elements of the distortion of the process of generalization in the form of slippage on secondary signs, a tendency to resonance in a person with a mixed type of character (stuck, excitable, with a tendency to impulsiveness, irritability, with manifestations vulnerabilities, pronounced obsessions and internal stress) were found out. The presence of psychopathy and hypomania, which indicated impulsive behavior, excessive activity, intrusiveness, and emotional instability was established according to Minnesota Multiphasic Personality Inventory test. Self-control was reduced, criticism of his condition and behavior was insufficient. The activity of attention was unstable, the concentration was reduced, with manifestations of distraction.
Treatment: haloperidol 5 mg per day, chlorpro-mazine 100 mg per day, quetiapine 600 mg per day, periciazinum 15 mg per day, aripiprazole 15mg per day, zuclopenthixol decanoate 400 mg intramuscularly 1 time per month, pregabalin 150 mg per day, sodium valproate 1350 mg per day, lamotrigine 300 mg per day, paroxetine 20 mg per day, dia-zepam 10 mg per day, phenazepam 1 mg per day,
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cyclodol 4 mg per day, individual psychotherapy, family psychotherapy - improvement.
On discharge: the patient was calm, behavior was ordered, mood changes were not observed. Obsessive phenomena had significantly decreased, did not determine the patient's behavior. He intended to take supportive treatment at home (pericia-zinum 15 mg per day, aripiprazole 15 mg per day, quetiapine 600 mg per day, cyclodol 2 mg per day) and get a job.
Diagnosis: mixed obsessive compulsive disorder, protracted course with decompensations, moderately disturbing social adaptation (code on International Classification of Diseases 10th Revision F42.2).
Thus, the presented clinical case demonstrates the comorbidity of Gilles de la Tourette syndrome and obsessive-compulsive disorder. Gender affiliation can be considered as an additional sanctioning
factor for the early onset of mental disorders. Obsessive compulsive disorder in a patient has become protracted, with prolonged decompensations requiring inpatient treatment. Emotional instability, impulsivity, obsessions and compulsions affecting the social functioning of not only the patient himself, but also those around him, as well as pronounced behavioral disturbances led to moderate social maladjustment. Because of the poor response to drug therapy, the doctors had to resort to a combination of typical antipsychotics with second-generation antipsychotics, mood stabilizers, and antidepressants. Comorbidity of mental disorders determined the complexity of therapeutic measures with the use of psychotherapeutic interventions, which made it possible to achieve an improvement in the mental state and avoid disability of the patient.
The authors declare no conflict of interest.
REFERENCES
1. Anagnostopoulos DC, Korlou S, Sakellariou K. et al. Comorbid psychopathology and clinical symptomatology in children and adolescents with obsessive-compulsive disorder. Psychiatriki. 2016;27(1):27-36.
2. Delorme C, Salvador A, Valabrègue R. et al. Enhanced habit formation in Gilles de la Tourette syndrome. Brain. 2016;139(2):605-15.
doi: https://doi.org/10.1093/brain/awv307
3. Milad MR, Rauch SL. Obsessive-compulsive disorder: beyond segregated cortico-striatal pathways. Trends Cogn Sci. 2012;16(1):43-51.
doi: https://doi.org/10.1016/j.tics.2011.11.003
4. Robertson MM. The Gilles De La Tourette syndrome: the current status. Arch Dis Child Educ Pract Ed. 2012;97:166-175.
DOI: https://doi.org/10.1136/archdischild-2011-300585
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СПИСОК ЛИТЕРАТУРИ
1. Comorbid psychopathology and clinical symptomatology in children and adolescents with obsessive-compulsive disorder / Anagnostopoulos D. C. et al. Psychiatriki. 2016. Vol. 27, N 1. P. 27-36. PMID: 27110880.
2. Enhanced habit formation in Gilles de la Tourette syndrome / Delorme C. et al. Brain. 2016. Vol. 139, N 2. P. 605-615. DOI: https://doi.org/10.1093/brain/awv307
3. Milad M. R., Rauch S. L. Obsessive-compulsive disorder: beyond segregated cortico-striatal pathways. Trends Cogn Sci. 2012. Vol. 16, N 1. P. 43-51. DOI: https://doi.org/10.1016/j.tics.2011.11.003
4. Robertson M. M. The Gilles De La Tourette syndrome: the current status. Arch Dis Child Educ Pract Ed. 2012. Vol. 97. P. 166-175.
DOI: https://doi.org/10.1136/archdischild-2011-300585
5. Symptom dimensions are associated with age of onset and clinical course of obsessive-compulsive disorder / Kichuk S. A. et al. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2013. Vol. 44. P. 233-239. DOI: https://doi.org/10.1016/jjocrd.2012.10.002
Стаття надшшла до редакци 15.02.2019
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