Suppression of extrapyramidal side effects of doxepin by thalamic deep brain stimulation for Tourette syndrome

Abstract

Thalamic deep brain stimulation (DBS) has been shown to improve tics in patients with Tourette syndrome (TS).1 However, problems with psychosocial adaptation and comorbid depression can complicate treatment and necessitate concomitant antidepressant therapy.2,3 Here, we describe the occurrence of an acute movement disorder including dystonia caused by the tricyclic antidepressant doxepin that interfered with the otherwise effective DBS treatment of a malignant motor tic in a patient with TS. ### Case report. A right-handed 31-year-old man with TS ( Diagnostic and Statistical Manual of Mental Disorders, 4th edition ) had compulsory left-hand pounding of the chin leading to chronic ulceration of the skin, loss of teeth, and mandibular fractures (video 1, segment 1, on the Neurology ® Web site at www.neurology.org). This left-sided violent tic was accompanied by bilateral milder motor tics (e.g., touching the lips, his nose, or his glasses with the left or right hand or twisting his ankle) and grunting as a single vocal tic (Yale Global Tic Severity Score [YGTSS] 77). Obsessive and compulsive symptoms (OCS) presented as compulsive ranging, counting, and touching, as well as intrusive thoughts (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] 24). Disability and social isolation were associated with recurrent depression and 2 …