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Tourette's syndrome and schizophrenia

About a case report

Salma, Hentati; Rim, Sellami; Imen, Abida; Jaweher, Masmoudi

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doi: 10.4103/psychiatry.IndianJPsychiatry_210_17
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Tourette's syndrome (TS) is a rare neurobiological disease characterized by a combination of multiple motor and one or more vocal tics for at least 1 year in duration.[1] Despite a degree of overlap in clinical symptoms and responsiveness to pharmacological treatment, psychotic illnesses were less commonly reported, from other comorbidities, in patients diagnosed with TS.[2] The existing literature is based, essentially, on small case series and multiple case reports of individuals with both illnesses.[2] We present a case of comorbid TS and schizophrenia in a young patient.

A single 20-year-old male patient, without personal history and who had an uncle with schizophrenia, presented to our outpatient department with his mother. His chief complaints were lack of interacting with family members, academic decline, and abnormal movements and sounds. Detailed evaluation of the history revealed that at the age of 19, the patient developed several sudden, rapid, repetitive, conscious, and uncontrollable episodes of abnormal motor vocalizations and behaviors which consisted of swinging up his arms, shoulder shrugs, blinking eyes, and sound of hiccups. The neurologic examination was normal. Instrumental analyses including blood count, electrocardiography, and cranial computed tomography yielded normal findings. At that time, the patient was diagnosed with TS. He was treated with olanzapine at the dose of 10 mg, but he refused to take any medication or medical follow-up. Eight months later, added to the tics, suspiciousness, delusion of persecution, and bewitchment occurred. Moreover, he showed amotivation, concentration disorders with academic decline, and marked psychosocial dysfunction. These symptoms lasted for several months before the second consultation. A diagnosis of schizophrenia (as per the DSM5) was made in addition to TS. Hence, the patient received psychoeducation and olanzapine (10 mg daily). Within 10 weeks of treatment, motor and vocal tics disappeared while psychotic symptoms were partially improved. Then, the patient refused medical checkup, but his mother stated us that he was complying with neuroleptic therapy. Furthermore, he could do professional computer training.

This comorbidity calls to the mind the possibility of whether both disorders may share a common background.[2] First of all, it is necessary to know that coexistence of schizophrenia in TS has been rarely noted in the literature.[2] An American study carried out on 399 children and adolescents with TS[3] found that comorbidity rate of schizophrenia was 2.5%. Moreover, previous studies have shown that tic-like symptoms might manifest during treatment of schizophrenia with antipsychotics. Compelling evidence suggests that this phenomenon is due to an increased central dopaminergic activity.[4] However, in our case, tics preceded the onset of psychotic symptoms. It appears that the order of onset with TS occurring first and schizophrenia later has been reported in rare cases.[25] Similarly, Müller et al.[2] have reported five adults with comorbid TS and schizophrenia. All of their patients first showed symptoms of TS, followed by symptoms of schizophrenia. Four of these had an adult onset of their schizophrenia, and one had an onset in later adolescence. In addition, Takeuchi et al.[5] described a TS patient who experienced schizophrenic episode 11 years after TS onset. Another case report diagnosed with tic syndrome at the age of 9.5 years developed schizophrenia at the age of 20 years.[6]

A family history of psychosis was noted among our patient. In the study of Takeuchi et al.,[5] it was revealed a psychotic illness among the uncle, too. This finding was also described by many other studies which suggest a hereditary predisposition to psychoses among patient with TS, especially in males.[3] Although contribution of many factors and process in both disorders has been discussed, their pathological mechanisms are poorly known and further studies are required.

Clinically other symptoms such as echolalia and echopraxia often occur in TS, but they were also frequently described in schizophrenia.[2] Further, it was reported that patients suffering from TS could develop “schizophrenia-like” symptoms, characterized by paranoid ideation, feelings of presence or persecution, and control phenomena.[7] Such symptoms were found among 12% patients with TS in an epidemiological study in North Dakota.[8] Similarly, our patient diagnosed with TS developed, after a period, psychotic symptoms. It was demonstrated that dopaminergic neurotransmission was implicated in its pathophysiology.[2]

In our case, added to the psychoeducation, olanzapine monotherapy was used to treat tics and psychotic symptoms, as well. Similarly, olanzapine was used successfully in treating late-onset antipsychotic-induced vocal tics in a schizophrenic patient.[9] For a long time, typical antipsychotic has been shown to be the most beneficial drugs in schizophrenia and TS.[2] Hence, it seems that the almost therapeutic strategies, used to treat schizophrenia, are effective in TS. Although cooccurrence of TS and schizophrenia is rarely reported, similarities suggest that relationship between these diagnoses might be. Therefore, whenever a patient presents with either of this diagnosis, evaluation should include the other disorders.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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