SIB in Comorbid Tourettes and OCD

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SIB in Comorbid Tourettes and OCD

• Case Study of Adolescent

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• Tourettes alone incidence of SIB estimated at
  25-50
• More than half of those with Tourettes 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.

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Current therapeutic approaches

• Treatment of comorbid Tourettes and OCD SSRIs
  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!

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Case history

• 16 year old white girl
• Received emergency treatment for new-onset SIB
• Prior diagnosis of Tourettes and comorbid OCD 5
  years.
• Prominent Tourettes 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 mothers
  diagnosis of breast cancer 1 year before onset of
  SIB.
• No history of medical problems reported.

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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

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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 shed 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.

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• 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

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• 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.

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• 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.

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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.

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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.

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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.
• Patients 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.

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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.

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summary

• Complex nature and treatment of severe SIB with
  comorbid Tourettes 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.