SIR: We repo Gilles de la Tourette syndrome (GTS) has an established link with obsessional symptoms, but its link with psychosis is less clear. Only one case of schizophrenia, GTS, and obsessive-compulsive disorder (OCD) occurring together is reported in literature.
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Mr. G., a 24-year-old unemployed man, began to show motor tics (involving eyes, face, and all four limbs) at the age of 6, and vocal tics (grunting, clearing his throat, and occasional coprolalia) at the age of 10. Around the same time, ritualistic behavior appeared, and by the age of 15, he developed complex behaviors (repeatedly brushing his teeth, putting on clothes in a certain order, counting before eating, and checking for symmetry).
At the age of 15, he started complaining that people gave him strange looks. He described hearing female voices saying derogatory things about him amongst themselves. He had his first contact with the psychiatric services, and a diagnosis of GTS was made. A CT scan and an ophthalmic examination (for Kayser-Fleischer ring) were normal. Neuropsychological testing revealed a global IQ of 81 on the Wechsler Adult Intelligence Scale—Revised. Over the next 3 to 4 years, hallucinations became worse and he developed bizarre and persecutory ideas, including Schneiderian first-rank symptoms (thought insertion, thought broadcast, passivity of emotions). A diagnosis of schizophrenia was made in addition to GTS. He was admitted several times to psychiatric hospitals, from which he repeatedly absconded. For the past 3 years he has been in a medium-secure unit.
Schizophrenic symptoms responded poorly to traditional neuroleptics, but improved when clozapine was added to sulpiride (a specific dopamine D2 antagonist to control tics). On the Brief Psychiatric Rating Scale, his scores came down from 28 to 9. The tics have decreased in frequency, but facial and lower limbs tics are still obvious. He occasionally shows simple vocal tics, but coprolalia has disappeared. He has given up some of the rituals (brushing his teeth) but persists with others (symmetry and counting). On the Maudsley Obsessive-Compulsive scales, his scores are within normal range.
This patient developed GTS along with marked obsessional symptoms (fulfilling DSM-IV criteria A and B for OCD) and schizophrenia. Schizophrenia and GTS have common features, such as hyperactivity of dopaminergic neurons in the striatum, altered metabolic activity in frontal cortex,
+2 impaired executive functioning,
+3,+4 and therapeutic response to dopamine D
2 antagonists. There is a potential for misdiagnosis because motor tics of GTS can be mistaken for mannerisms and stereotypies of schizophrenia. GTS is still underreported and might simply go unrecognized for years.
+5 Finally, it is possible that treatment of GTS with traditional neuroleptics may mask or delay the onset of schizophrenic illness, thereby making links between the two disorders more obscure. It is interesting that in our patient, the schizophrenic symptoms came under control only with clozapine, which blocks D
2 receptors weakly, whereas the tics appear to have benefited from the addition of a specific D
2 antagonist. Further research in neurochemistry of schizophrenia may enhance our understanding of the links between these two conditions.