Download SIB in Comorbid Tourette’s and OCD

SIB in Comorbid
Tourette’s and OCD
Case Study of Adolescent
• Tourette’s alone: incidence of SIB estimated at
25-50%
• More than half of those with Tourette’s have
prominent obsessive-compulsive sympotoms or
comorbid OCD.
• Comorbid tend to have significantly more violent
obsessions and self-injurious compulsions than
OCD alone.
• When comorbid, the SIB found to be more
severe.
Current therapeutic approaches
• Treatment of comorbid Tourette’s and OCD:
SSRI’s or clomipramine + neuroleptic.
• Drugs alone do- not eliminate obsessivecompulsive symptoms.
• CBT also helps.
• When severe SIB presents, serious measures
are taken, including Benzos as adjunct, even
botulism toxin, and mechanical restraints!
Case history
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16 year old white girl
Received emergency treatment for new-onset SIB
Prior diagnosis of Tourette’s and comorbid OCD 5 years.
Prominent Tourette’s symptoms of motor and vocal tics,
and OCD symptoms included obsessions.
• One prior psychiatric hospitalization for suicidal ideation
6 months before SIB
• Psychosocial stressors included mother’s diagnosis of
breast cancer 1 year before onset of SIB.
• No history of medical problems reported.
Current medications
Clonazepam O.5 mg
Clonidine 0.1 mg
Olanzapine 15mg/day 2 days prior
Quetiapine for 3 previous 3 weeks
Last several years pimozide 4mg –stopped due to
“frequent oculogyric crises”
Trials of citalopram and paroxetine w/no effect
Dystonic reaction to haloperidol
Emergency treatment
• SIB began 5 days before emergency room treatment: biting her
tongue repeatedly, increasing frequency and severity.
• Mental Status Exam in ED, patient was alert, oriented, no evidence
of psychosis.
• Every 15 minutes, patient continued to open her mouth and bite
down on her tongue, cry in pain, put a wet washcloth in mouth to
soak up blood.
• Stated she was not biting on purpose but “could not help it”.
• Recently she’d begun worrying about hurting herself.
• Initially began biting to “test” whether she would hurt herself.
• Relief/intially no pain or damage, followed by worry, repeated biting,
pain and damage began and increased.
• Team estimated she compulsively acted to feel relief from worries,
but could not break cycle. Possible new motor tic, but no tics
observed during interview.
• While in ED, lip cheek, tongue biting continued every 15
min. despite following pharmacological interventions:
• Lorazepam 7mg in iv
• Morphine 6 mg in iv
• Benztropine 2mg in iv
• Diphenhydramine 100 mg in iv
• Chlorpromazine 50 mg in iv
• Risperidone 4.5 mg
• Subsequently transferred to Inpatient Service
• After admission evaluated by Oral Maxillofacial
surgery and given antibiotics intravenously.
• Started on risperidone 1 mg, clonazepam 1 mg,
clonidine 0.1mg also chlorpromazine and
diphenhydramine in IV.
• New compulsion to poke her eyes w/fingers and
pull out her IV every 5-10 min.
• Continued distress, saying she did not want to
harm herself.
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After 18 hours transferred to ICU for monitored sedation abd nasotracheal intubation
to break cycle and prevent irreparable damage.
Clomipramine 50mg nasogastric tube w/planned incremental increase to 200mg
Remained on other meds while in ICU adding clonidine 0.1 through skin patch.
ECG monitored regularly.
On third day, ECG revealed prolonged QTc interval, contraindicating more
clomipramine.
OMFS injected botulism toxin into patients facial muscles and fit for bite block.
Blood cultures positive for Staphylococcus non-aureus.
5th day risperidone increased, clominpramine increased, and patch changed due to
rash.
6th day patient was extubated, lip, cheek and togue had healed significantly
Returned to medical floor under constant observation. Patient reported intermittent
thoughts of biting tongue and poking her eyes but did not act w/same frequency;
reported greater control over thoughts.
Inpatient Pyschiatry
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Treatment team of child psychiatrist, child psychologist, psych intern,
pediatrician, pediatric nurse practitioner and ped nurses.
She was placed on individualized daily schedule of school group activities,
individual therapy and recreation therapy
During the week, she continued SIB though much reduced. Began
scratching forehead and face. Occasional motor tics, jerking her arm and
face uncontrollably.
Started on citalopram 10mg daily, increased gradually to 60mg. No
increase in clomipramine due to “QTc prolongation”. Monitored by pediatric
cardiologist during rest of stay.
Clomipramine slowly decreased to 75mg, clonazepam increased to 1mg.
Risperidone as adjunct to Citalopram for OCD symptoms discontinued
because patient developed galactorrhea.
Began aripiprazole 10 mg, but symptoms worsened markedly.
Reintroduced risperidone at lower dose and upped the aripiprazole; patient
tolerated.
Complex medication regimen
• Closely monitored throughout hospitalization.
• Several adverse effects not seen:
“extrapyramidal symptoms” or akathisia.
• Patient worried about oculogyric crises.
• Diphenhydramine continued as a result.Patient
worried dose decrease nearing her discharge
would bring about these adverse effects.
• Outpatient team in hospital, frequent contact,
gradual decrease of diphenhydramine and
antipsychotics while she underwent CBT.
Psychological treatment
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Therapy included replacing SIB w/less destructive behaviors: squeezing a
stress ball slowly took place of scratching compulsion.
Patient wore winter gloves to reduce damage when SIB occurred.
Face scratching replaced by pushing out her front tooth to point of losing it.
Patient began wearing large boxing gloves instead, voluntarily and w/ her
families help and cooperation.
SIB diminished w/this treatment.
Cognitive work for reducing general anxiety.
Over past 5 years, anxiety symptoms moved from general “worries” to OCD.
Patient’s urge “not to hurt herself” increased until filled her mind.
Cycle of worrying about hurting herself, actually hurting herself, feeling
some relief, experiencing pain and shame, worrying again.
Therapy aimed at targeting initial worries, challenge rationality, alternative
thoughts before they became compulsions.
Made sig. progress over time and was able to apply skills to other life
situations of increased anxiety so that SIB did not occur.
End of two months inpatient
Patient no longer engaged in severe SIB
Mild SIB twice a day.
She managed SIB and motor/vocal tics:
decreased frequency and severity.
Discharged from psych service –two weeks
partial.
summary
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Complex nature and treatment of severe SIB with comorbid Tourette’s and OCD.
First case of successful treatment for such severity.
Success =Safe behavior: two weeks minimal SIB (no damage)
Factors of treatment: patient did not want to engage in SIB. Patient receptive to
treatment, worked “feverishly” to implement new strategies.
Family support
Multidisciplinary team informed treatment: all current literature and case histories to
date.
Combination of psychological, pharmacological interventions to ensure safety and
max. benefit.
Patient and family left with detailed relapse plan including steps to treat SIB, possible
adverse reactions to “complex med. Regimen” and contact info., emergency sources.
Frequent contact w/ outpatient team.
Weekly CBT, coping skills and meds for anxiety.
Patient not tested for PANDAS ( pediatric autoimmune neuropschiatric disorders
associated w/ streptococcal infection.
In general, eval for PANDAS is warranted in furture cases.
Monitor drug-drug interactions must be done.