Tourette's Syndrome and Type 2 Bipolar Disorder

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Back to table of contents Previous article Next article LettersFull AccessTourette's Syndrome and Type 2 Bipolar DisorderLuís Fonseca, Joana Damásio, Marina Magalhães, and Joaquim DuarteLuís FonsecaPsychiatry and Mental Health Department, Braga Hospital, Braga, PortugalSearch for more papers by this author, Joana DamásioNeurology Department, Porto Hospital Centre, Porto, PortugalSearch for more papers by this author, Marina MagalhãesNeurology Department, Porto Hospital Centre, Porto, PortugalSearch for more papers by this author, and Joaquim DuartePsychiatry and Mental Health Department, Braga Hospital, Braga, PortugalSearch for more papers by this authorPublished Online:1 Jan 2011AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Tourette's syndrome is an inherited, childhood-onset neuropsychiatric disorder characterized by a fluctuating course of multiple chronic motor and phonic tics. Around 88% of Tourette's syndrome patients have comorbidity, the most common being attention-deficit/hyperactivity disorder, followed by obsessive compulsive disorder.1Case ReportA 34-year-old male patient with a history of Tourette's syndrome was seen for acute onset of insomnia, irritability, and overspending. He also presented slight neck jerking. He had been medicated with 600 mg of sulpiride and 10 mg of haloperidol for Tourette's syndrome. At this time, 500 mg of valproate was prescribed with symptomatic improvement. Antipsychotic medication was maintained. Four months later he presented with depressive mood, anhedonia, insomnia, loss of appetite, and diminished ability to concentrate of 1 month duration. Fluvoxamine was prescribed and titrated to 100 mg while the other drugs were maintained. Again he improved.Nine months later, the patient was seen for acute onset of insomnia, overspending, dysphoric mood, sexual disinhibition, and megalomaniac thoughts, and he was admitted to our unit. A brain MRI and thorough lab work returned normal results. Valproate was titrated to 1,000 mg, and we added 300 mg of quetiapine. Haloperidol and sulpiride were stopped without the worsening of neck jerking or the onset of new tics. Three weeks later, he presented no psychiatric symptoms and was discharged home.At the age of 13, our patient had acutely developed cervical motor tics. He started haloperidol, titrated to 6 mg, with symptomatic improvement. When he turned 18 the motor tics worsened, new ones involving the superior limbs appeared, and the onset of vocal tics (shouting repeatedly during his speech and coprolalia) occurred. Haloperidol augmentation to 10 mg improved these.Until the age of 23, the tics presented a waxing and waning course. At this age, cervical and mouth tics slightly improved and others began (scratching the genitalia, clothes pruning). Haloperidol was then stopped, and sulpiride titrated to 600 mg improved these symptoms. A slight neck jerking remained up to the time he presented to our unit.The clinical picture that emerged 9 months after the depressive syndrome was clearly a hypomanic state. The diagnosis of bipolar disorder type II could then be confidently made.2Hypomania could be considered an iatrogenic effect of antidepressant medication. However, it is unlikely due to the antimanic effect of valproate and sulpiride3 and the 9 months that had lapsed since the antidepressant was prescribed.DiscussionComorbidity between Tourette's syndrome and bipolar disorder, although infrequent, has been reported.4 A modulation defect of the mesencefalic nuclea in certain areas of the cortical-limbic system, ventral striatum, and sensory motor cortical regions could explain the association. The onset of mania or bipolar disorder in neuropsychiatric disorders with predominant subcortical dysfunction (e.g., Huntington's) further supports it.1,5The onset of vocal tics at the age of 18 fulfilled diagnostic criteria for Tourette's syndrome.5 Currently, neck jerking is the only remaining tic. This is consistent with the known decrease of tic frequency and intensity during adolescence in about two-thirds of children with Tourette's syndrome, as well as its frequent remission in adulthood.6Psychiatry and Mental Health Department, Braga Hospital, Braga, PortugalNeurology Department, Porto Hospital Centre, Porto, PortugalPsychiatry and Mental Health Department, Braga Hospital, Braga, Portugal1. Robertson M: Mood disorders and Gilles de la Tourette's syndrome: an update on prevalence, etiology, comorbidity, clinical associations and implications. J Psychosom Res 2006; 61:349–358Crossref, Medline, Google Scholar2. Muller-Oerlinghausen B , Berghofer A , Bauer M: Bipolar disorder. Lancet 2002; 19:359241–247Crossref, Google Scholar3. Cristhie J , Whalley L , Hunter R, et al.: Sulpiride treatment of acute mania with a comparison of the effects of plasma hormone concentrations of lithium and sulpiride treatment. J Affective Disord 1989; 16:115–120Crossref, Medline, Google Scholar4. Berthier M , Kulisevsky J , Campos V: Bipolar disorder in adult patients with Tourette's syndrome: a clinical study. Biol Psychiatry 1998; 43:364–370Crossref, Medline, Google Scholar5. Harris K , Singer H: Tic disorders: neural circuits, neurochemistry and neuroimmunology. J Child Neurol 2006; 21:678–689Crossref, Medline, Google Scholar6. Bloch M , Leckman J , Zhu H, et al.: Caudate volumes in childhood predict symptom severity in adults with Tourette syndrome. Neurology 2005; 65:1253–1258Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 23Issue 1 Winter 2011Pages E26-E26 Metrics PDF download History Published online 1 January 2011 Published in print 1 January 2011