SIB in Comorbid Tourette’s and OCD

1. SIB in Comorbid Tourette’s and OCD Case Study of Adolescent

2. 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.

3. Current therapeutic approaches • Treatment of comorbid Tourette’s and OCD: SSRI’s or clomipramine + neuroleptic. • Drugs alone do- not eliminate obsessive-compulsive symptoms. • CBT also helps. • When severe SIB presents, serious measures are taken, including Benzos as adjunct, even botulism toxin, and mechanical restraints!

4. Case history • 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.

5. 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

6. 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.

7. 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

8. 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.

9. 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.

10. Inpatient Pyschiatry • 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.

11. 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.

12. Psychological treatment • 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.

13. 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.

14. summary • 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.