case challenge

Bipolar Disorder and Tourette Syndrome in Adults: A Treatment Challenge Manoj Puthiyathu, MD; and Gurjot Singh, MD

illes de la Tourette syn- der for more than 3 years, alcohol agitated behavior toward family drome (TS), character- dependence with physiological members. He reported conflicting G ized by chronic multiple dependence in early partial re- relationships with family mem- motor tics and one or more vocal mission, sedative-hypnotic abuse, bers and no psychiatric history in tics,1 has not been well recognized and TS. He was last evaluated in other family members. He also had in adults. There are many stud- an outpatient department during a a history of two suicide attempts, ies in the literature that provide regular follow-up session. He was the last one being 3 years ago evidence of bipolar disorder being very satisfied and compliant with when he tried to cut his neck with one of the comorbid disorders in the medications, and he had been a knife. His substance use history adult patients with TS.2 Treatment regularly following up in the out- included alcohol (drinking almost of TS in adults with bipolar disor- patient clinic. a pint daily for the past 2 years, der is very challenging and has not The patient’s medication in- with his longest period of absti- been exclusively studied. cluded pimozide 1 mg orally nence being about 2 months) and twice daily, quetiapine 100 mg sedative-hypnotics (he has taken CASE REPORT orally twice daily, trazadone 100 more than the prescribed dose of RS was a 41-year-old single, mg orally at bedtime, lamotrigi- clonazepam) for 2 years. He had white male who lived alone in an ne 50 mg, and clonazepam 1 mg no history delirium tremens, de- apartment and assisted his father three times daily. His psychiatric toxifications, or rehabilitations. in his plumbing business. RS had history included TS since child- a history of type one bipolar disor- hood with predominantly motor DISCUSSION and intermittently vocal tics. He Treatment of TS in this patient Manoj Puthiyathu, MD, is Chief Fellow has been treated with propranolol, has been very challenging because in Addiction Psychiatry, Bronx Lebanon gabapentin, and pimozide for the of co-occurring bipolar disorder Hospital. Gurjot Singh, MD, is a PGY-1 tics but the best response had been and substance use. He was on Resident, Bergen Regional Medical Center. with the pimozide. He had a docu- pimozide, one of the drugs ap- Address correspondence to: Manoj mented history of legal charges. proved by the U.S. Food and Drug Puthiyathu, MD, Bronx Lebanon Hospital; These included three instances of Administration (FDA) for TS. The 1276 Fulton Division, Bronx, NY 10457; drunk driving, assaultive behavior co-occurring bipolar disorder ne- email: [email protected]. with family, and more than five cessitated the adding of quetiap- Disclosure: The authors have no rel- inpatient psychiatric hospitaliza- ine. Clonazepam and lamotrigine evant financial relationships to disclose. tions. The last hospitalization was were prescribed for additional re- doi: 10.3928/00485713-20140108-02 4 months prior for aggressive and lief of his motor tics and bipolar

PSYCHIATRIC ANNALS 44:1 | JANUARY 2014 Healio.com/Psychiatry | 15 case challenge

disorder-depressive type, respec- men with regular monitoring. This case is a reminder of the tively. The patient had a very good He remained compliant with his complications and challenges we compliance with the regimen and medications, with no exacerba- face in an adult patient with TS it had been very effective for him. tion of symptoms and no hos- with co-occurring bipolar disorder The problem and challenge for pitalizations reported. The plan and substance abuse. this treatment was that pimozide was made to closely monitor the REFERENCES can interact with quetiapine to in- QT prolongation by following up 1. American Psychiatric Association. creases the risk for prolonged QT with regular electrocardiograms. Diagnostic and Statistical Manual of syndrome. The other challenge Lamotrigine did not provoke any Mental Disorders [text revision]. 4th ed. Washington, DC: American Psy- was that the lamotrigine (FDA- symptoms of TS after 2 months, chiatric Publishing; 2000. approved for bipolar disorder-de- but the plan is to keep a regular 2. Berthier ML, Kulisevsky J, Campos pressive type), according to a case watch on any exacerbation of VM. Bipolar disorder in adult pa- study, could provoke symptoms symptoms. The patient was given tients with Tourette’s syndrome: a clinical study. Biol Psychiatry. 3 of TS. The third challenge devel- education regarding clonazepam 1998;43(5):364-370. oped when patient started abusing abuse and will be monitored for 3. Seemüller F, Dehning S, Grunze clonazepam. any further abuse. He will be fol- H, Müller N. Tourette’s symptoms provoked by lamotrigine in a bi- Follow-up was performed af- lowing up in an outpatient clinic polar patient. Am J Psychiatry. ter 2 months on the same regi- once every month. 2006;163(1):159.

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