LETTERS
Psychogenic Disorder
(Pseudo-Tics)
Patient
in a
zures. There was no change in consciousness or incontinence during the
Movement
spells,
With
Tourette’s
Syndrome
SIR:Recently, Lang and colleagues described 6 patients with psychogenic abnormal movements in association with diagnosed organic movement disorders, including dystonia and essential tremor.1 Tourette’s syndrome (TS) is a genetically determined illness, the etiology The
of which complex
take
bizarre
times
is not motor
forms
psychogenic. tics of TS may
and
misinterpreted
chogenic
are someas being
in origin.2
We
and the movements
were highly
suggestible. The patient and her parents referred to these movements as her “bad tics.” At times only fragments of the complex movement occurred, consisting of shaking of one or more limbs or shaking of the head. These movements resembled complex motor tics. Attempts to adjust her pimozide dosage had no effect on the frequency or severity of her episodes. After several episodes were witnessed by us, they were diagnosed as representing a psychogenic movement disorder. Pimozide dosage was reduced to its baseline level. The patient was referred to a psychiatrist, who diagnosed borderline personality disorder and noted that the spells
psy-
now,
however, report a patient with TS who developed associated abnormal movements with features indicative of a psychogenic disorder.
were associated
with prominent
second-
ary gain, including avoiding social, cational, and domestic responsibilities
and maintaining financial support from her parents.
edu-
and other The episodes
disappeared after a course of psychotherapy lasting several weeks.
CASE
REPORT This
An 18-year-old woman had a history since early childhood of infrequent re-
petitive
throat
clearing
and obsessional
counting, probably representing undiagnosed mild TS. There was no family history of tics. At age 16, following sudden withdrawal of chronic narcotic analgesia (codeine, pentazocine) therapy, she developed severe simple and complex motor and vocal tics. Symptoms gradually lessened over the next several months, during which time she also had
echolalia,
coprolalia,
and echopraxia.
In
prominent obsessive-compulsive symptoms were present. This case was previously reported by us.3 Tics and obsessive-compulsive symptoms addition,
were well controlled for a period of several months with a combination of pimozide 2mg tid and fluoxetine 20mg bid. However, plex movements
she then developed comconsisting of slumping or to the floor or bed with
in a chair rhythmic tonic-clonic-like of all limbs,
JOURNAL
resembling
OF
movements pseudo-sei-
NEUROPSYCHIATRY
patient
with
tics that were well neuroleptic drugs, developed frequent movements, which be tics by the
patient,
members,
and
cians.
movements
atypical highly
The
TS had
by her
initially
family
by her physiwere quite
for recognized suggestible,
chronic
controlled with but she then complicated were thought to
failed
tics, were to re-
spond to adjustments of tic-suppressing medications, were associated with clear secondary gain, and improved following psychotherapy, features indicative of a psychogenic movement disorder. The occurrence of psychogenic movements in a patient with TS seems analogous to the known occurrence of pseudo-seizures in patients with epilepsy, and the term “pseudo-tics” may therefore be appropriate. Although the pseudo-tics
in our patient were largely manifested as bizarre, complicated movements resembling pseudo-seizures, it is possible
that
other
TS patients
experience psychogenic movements that are more typical of, and perhaps indistinguishable from, true motor or vocal tics. The diagnosis of pseudo-tics implies that these movements either occur because of unconscious psychodynamic factors as part of a conversion disorder or are produced consciously and voluntarily as malingering or as an attempt to embellish symptoms. The issue of voluntary control over tics has long been problematic when considering TS patients. Patients with TS characteristically show at least some ability to voluntarily suppress tics for variable time periods. Furthermore, it is well known that TS patients can use and adapt their tics in a directed fashion based on specific social settings. For example, on occasion, lechires to groups of TS patients have been punctuated by supposedly involuntary shouts of “shut up,” “sit down,” and “boring!” Some TS patients have reported that “involuntary” touching is sometimes useful in “breaking the ice” to meet new people in certain social situations. Lang has pointed out that, in contradistinction to patients with other hyperkinetic movement disorders, most TS patients interpret their movements
as being
voluntarily
produced.4 He suggests, therefore, that tics are not truly involuntary movements
but
rather
more
closely
resemble compulsive acts that are performed intentionally in response to an irresistible inner urge. This conclusion, however, conflicts with family studies of TS that indicate that many affected individuals are completely unaware of tics that are
347
LETTERS
observed
by the
examiners.5
Even
patients who recognize their tic disorders often underestimate the number and frequency of tics that are actually
observed
by physicians.
Despite these phenomenologic and mechanistic perplexities, our experience suggests that some patients
with
TS may
develop
psycho-
diagnosis should be considered for TS patients when an unusual and resistant tic pattern appears, particularly after a period of good pharmacologic control and in patients with personality and emotional disturbances. The recognition of this phegenic
This
pseudo-tics.
nomenon
may
be important
of patients with ROGER KuiIAr’, M.D. CHERYL DEELEY, R.N., M.S. PETER G. CoMo, PH.D. Department of Neurology, University
CASE
of Rochester
This patient
depressive,
movement
disorders.
5:127-133 2. Fahn S: The
tics, in Gilles
Mov
clinical spectrum de is Tourette
by Fnedhoff
A: PsychoDisord
1990;
of motor Syndrome,
AJ, Chase
11:559-564
4. Lang A: Patient other movement 1991;
perception disorders.
of tics and Neurology
41:223-228
5. Kurlan
R, Behr J, Medved L, et al: Severity of Tourette’s syndrome in one large kindred: implication for determination of disease prevalence rate. Arch Neurol 1987;
44:268-269
Trazodone Treatment Targeted Aggression Mentally Retarded
of in a Man
SIR: Aggressive behavior is a symptom that occurs in a number of neuropsychiatric disorders, including dementia and mental retar-
348
or psychotic
episodes.
He
instances. ed-
TN. New Raven, 1982, pp 341-344 3. Lichter D, Majumdar L, Kurlan R: Opiate withdrawal unrnasks Tourette’s syndrome. Clin Neuropharmacol 1988; ited York,
a
had been treated with a variety of neuroleptics in the past without success. One month prior to referral, he was caught lying in wait with matches and aerosol spray, with a plan to set afire a female staff member whom he had been following and harassing. Since that time he continued to stalk her whenever possible and attempted aggressive physical contact with her in a number of
NY
organic
of aggressive
carried
tal retardation of impulsive aggression, induding assaults and suicide attempts involving hanging, wrist cutting, and head banging. This was in the setting of chronic affective lability without sustained manic,
TS.
with
acting out. diagnosis of menand had a 15-year history
management
References 1. Ranawaya R, Riley 0, Lang genic dyskinesias in patients
inmate in a correctional was referred for pharmacologic
facility
School
Rochester,
REPORT
A 33-year-old
in the
management
of Medicine,
dation. We here report the efficacy of trazodone (Desyrel), a drug useful in treating impulsive aggression in neuropsychiatric patients) in ameliorating planned targeted assaultive aggression in a patient with mental retardation.
Medication regimen at time of evaluation consisted of trifluoperazine 5mg po bid and diphenhydraniine 50mg po bid. Physical
exam
revealed
choreoathe-
toid movements consistent with tardive dyskinesia, but the remainder of the neurologic exam was nonlocal. Mental status exam was remarkable for tangential and mildly pressured speech, euthymic mood but labile affect, and a lack of suicidal ideation or formal thought disorder except for the persistent preoccupation noted above. The patient related a number of assaultive plans to punish the staff member for her inattention.
Cognitive testing revealed impaired fund of knowledge, attention, and concentration consistent with mild to moderate mental retardation. Laboratory values including complete blood count, electrolytes, liver and thyroid function tests, heavy metal screen, and sedimen-
tation
rate were all normal
serum
creatinine
except
of 1.7 mEq/dl
for a and
a
urinalysis revealing proteinuria and hematuria. (Subsequent urologic workup revealed nephrolithiasis.) The patient was diagnosed as mildly mentally retarded with associated organic personality disorder and episodes of targeted aggression. It was decided to treat the patient with trazodone 100mg po ha. After 1 week he was noted to be less affectively labile and more cognitively focused, and he had stopped harassing the staff member. By week 2 the patient had obtained a job sweeping up in the unit, the first time he had ever held a job in prison. Six weeks after initiation of trazodone he had only one aggressive outburst (compared to two a week previously), and trifluoperazine had been reduced to 5 mg qd without untoward behavioral effect. Harassment
of the staff member had completely stopped. Three months after consultation, he remains euthymic, cent episodes of planned assault. Trazodone has ful in the treatment gressive
and
been reported useof impulsive-ag-
self-injurious
in the populations We
believe
with no reor unplanned
this
behavior
noted
above.
to be the
first
re-
ported instance of cessation of planned and targeted aggressive behavior in a patient treated with trazodone. These findings await replication. LAWSON BERNSTEIN, M.D. Western Psychiatric Institute and Clinic and Department of Corrections, State of Pennsylvania
References 11. Greenwald Serotonergic
banging 1465
BS, Mann treatment in dementia.
DB, Silverman of screaming Lancet 1986;
SM:
and 2:1464-
2. Simpson DM, Foster 0: Improvement in organically disturbed behavior with trazodone treatment. J Clin Psychiatry 1986; 47:191-193 3. O’Neil M, Page N, Eichelnian B: Trypto-
phan-trazodone
treatment
of aggressive
behavior. Lancet 1986; 2:859-860 4. Pinner F, Rich CL: Effects of trazodone aggressive behavior in seven patients with organic mental disorders. Am chiatry 1988; 145:1295-1296
VOLUME
4
#{149} NUMBER
3
#{149} SUMMER
on
J Psy-
1992
Psychogenic Disorder
(Pseudo-Tics)
Patient
in a
zures. There was no change in consciousness or incontinence during the
Movement
spells,
With
Tourette’s
Syndrome
SIR:Recently, Lang and colleagues described 6 patients with psychogenic abnormal movements in association with diagnosed organic movement disorders, including dystonia and essential tremor.1 Tourette’s syndrome (TS) is a genetically determined illness, the etiology The
of which complex
take
bizarre
times
is not motor
forms
psychogenic. tics of TS may
and
misinterpreted
chogenic
are someas being
in origin.2
We
and the movements
were highly
suggestible. The patient and her parents referred to these movements as her “bad tics.” At times only fragments of the complex movement occurred, consisting of shaking of one or more limbs or shaking of the head. These movements resembled complex motor tics. Attempts to adjust her pimozide dosage had no effect on the frequency or severity of her episodes. After several episodes were witnessed by us, they were diagnosed as representing a psychogenic movement disorder. Pimozide dosage was reduced to its baseline level. The patient was referred to a psychiatrist, who diagnosed borderline personality disorder and noted that the spells
psy-
now,
however, report a patient with TS who developed associated abnormal movements with features indicative of a psychogenic disorder.
were associated
with prominent
second-
ary gain, including avoiding social, cational, and domestic responsibilities
and maintaining financial support from her parents.
edu-
and other The episodes
disappeared after a course of psychotherapy lasting several weeks.
CASE
REPORT This
An 18-year-old woman had a history since early childhood of infrequent re-
petitive
throat
clearing
and obsessional
counting, probably representing undiagnosed mild TS. There was no family history of tics. At age 16, following sudden withdrawal of chronic narcotic analgesia (codeine, pentazocine) therapy, she developed severe simple and complex motor and vocal tics. Symptoms gradually lessened over the next several months, during which time she also had
echolalia,
coprolalia,
and echopraxia.
In
prominent obsessive-compulsive symptoms were present. This case was previously reported by us.3 Tics and obsessive-compulsive symptoms addition,
were well controlled for a period of several months with a combination of pimozide 2mg tid and fluoxetine 20mg bid. However, plex movements
she then developed comconsisting of slumping or to the floor or bed with
in a chair rhythmic tonic-clonic-like of all limbs,
JOURNAL
resembling
OF
movements pseudo-sei-
NEUROPSYCHIATRY
patient
with
tics that were well neuroleptic drugs, developed frequent movements, which be tics by the
patient,
members,
and
cians.
movements
atypical highly
The
TS had
by her
initially
family
by her physiwere quite
for recognized suggestible,
chronic
controlled with but she then complicated were thought to
failed
tics, were to re-
spond to adjustments of tic-suppressing medications, were associated with clear secondary gain, and improved following psychotherapy, features indicative of a psychogenic movement disorder. The occurrence of psychogenic movements in a patient with TS seems analogous to the known occurrence of pseudo-seizures in patients with epilepsy, and the term “pseudo-tics” may therefore be appropriate. Although the pseudo-tics
in our patient were largely manifested as bizarre, complicated movements resembling pseudo-seizures, it is possible
that
other
TS patients
experience psychogenic movements that are more typical of, and perhaps indistinguishable from, true motor or vocal tics. The diagnosis of pseudo-tics implies that these movements either occur because of unconscious psychodynamic factors as part of a conversion disorder or are produced consciously and voluntarily as malingering or as an attempt to embellish symptoms. The issue of voluntary control over tics has long been problematic when considering TS patients. Patients with TS characteristically show at least some ability to voluntarily suppress tics for variable time periods. Furthermore, it is well known that TS patients can use and adapt their tics in a directed fashion based on specific social settings. For example, on occasion, lechires to groups of TS patients have been punctuated by supposedly involuntary shouts of “shut up,” “sit down,” and “boring!” Some TS patients have reported that “involuntary” touching is sometimes useful in “breaking the ice” to meet new people in certain social situations. Lang has pointed out that, in contradistinction to patients with other hyperkinetic movement disorders, most TS patients interpret their movements
as being
voluntarily
produced.4 He suggests, therefore, that tics are not truly involuntary movements
but
rather
more
closely
resemble compulsive acts that are performed intentionally in response to an irresistible inner urge. This conclusion, however, conflicts with family studies of TS that indicate that many affected individuals are completely unaware of tics that are
347
LETTERS
observed
by the
examiners.5
Even
patients who recognize their tic disorders often underestimate the number and frequency of tics that are actually
observed
by physicians.
Despite these phenomenologic and mechanistic perplexities, our experience suggests that some patients
with
TS may
develop
psycho-
diagnosis should be considered for TS patients when an unusual and resistant tic pattern appears, particularly after a period of good pharmacologic control and in patients with personality and emotional disturbances. The recognition of this phegenic
This
pseudo-tics.
nomenon
may
be important
of patients with ROGER KuiIAr’, M.D. CHERYL DEELEY, R.N., M.S. PETER G. CoMo, PH.D. Department of Neurology, University
CASE
of Rochester
This patient
depressive,
movement
disorders.
5:127-133 2. Fahn S: The
tics, in Gilles
Mov
clinical spectrum de is Tourette
by Fnedhoff
A: PsychoDisord
1990;
of motor Syndrome,
AJ, Chase
11:559-564
4. Lang A: Patient other movement 1991;
perception disorders.
of tics and Neurology
41:223-228
5. Kurlan
R, Behr J, Medved L, et al: Severity of Tourette’s syndrome in one large kindred: implication for determination of disease prevalence rate. Arch Neurol 1987;
44:268-269
Trazodone Treatment Targeted Aggression Mentally Retarded
of in a Man
SIR: Aggressive behavior is a symptom that occurs in a number of neuropsychiatric disorders, including dementia and mental retar-
348
or psychotic
episodes.
He
instances. ed-
TN. New Raven, 1982, pp 341-344 3. Lichter D, Majumdar L, Kurlan R: Opiate withdrawal unrnasks Tourette’s syndrome. Clin Neuropharmacol 1988; ited York,
a
had been treated with a variety of neuroleptics in the past without success. One month prior to referral, he was caught lying in wait with matches and aerosol spray, with a plan to set afire a female staff member whom he had been following and harassing. Since that time he continued to stalk her whenever possible and attempted aggressive physical contact with her in a number of
NY
organic
of aggressive
carried
tal retardation of impulsive aggression, induding assaults and suicide attempts involving hanging, wrist cutting, and head banging. This was in the setting of chronic affective lability without sustained manic,
TS.
with
acting out. diagnosis of menand had a 15-year history
management
References 1. Ranawaya R, Riley 0, Lang genic dyskinesias in patients
inmate in a correctional was referred for pharmacologic
facility
School
Rochester,
REPORT
A 33-year-old
in the
management
of Medicine,
dation. We here report the efficacy of trazodone (Desyrel), a drug useful in treating impulsive aggression in neuropsychiatric patients) in ameliorating planned targeted assaultive aggression in a patient with mental retardation.
Medication regimen at time of evaluation consisted of trifluoperazine 5mg po bid and diphenhydraniine 50mg po bid. Physical
exam
revealed
choreoathe-
toid movements consistent with tardive dyskinesia, but the remainder of the neurologic exam was nonlocal. Mental status exam was remarkable for tangential and mildly pressured speech, euthymic mood but labile affect, and a lack of suicidal ideation or formal thought disorder except for the persistent preoccupation noted above. The patient related a number of assaultive plans to punish the staff member for her inattention.
Cognitive testing revealed impaired fund of knowledge, attention, and concentration consistent with mild to moderate mental retardation. Laboratory values including complete blood count, electrolytes, liver and thyroid function tests, heavy metal screen, and sedimen-
tation
rate were all normal
serum
creatinine
except
of 1.7 mEq/dl
for a and
a
urinalysis revealing proteinuria and hematuria. (Subsequent urologic workup revealed nephrolithiasis.) The patient was diagnosed as mildly mentally retarded with associated organic personality disorder and episodes of targeted aggression. It was decided to treat the patient with trazodone 100mg po ha. After 1 week he was noted to be less affectively labile and more cognitively focused, and he had stopped harassing the staff member. By week 2 the patient had obtained a job sweeping up in the unit, the first time he had ever held a job in prison. Six weeks after initiation of trazodone he had only one aggressive outburst (compared to two a week previously), and trifluoperazine had been reduced to 5 mg qd without untoward behavioral effect. Harassment
of the staff member had completely stopped. Three months after consultation, he remains euthymic, cent episodes of planned assault. Trazodone has ful in the treatment gressive
and
been reported useof impulsive-ag-
self-injurious
in the populations We
believe
with no reor unplanned
this
behavior
noted
above.
to be the
first
re-
ported instance of cessation of planned and targeted aggressive behavior in a patient treated with trazodone. These findings await replication. LAWSON BERNSTEIN, M.D. Western Psychiatric Institute and Clinic and Department of Corrections, State of Pennsylvania
References 11. Greenwald Serotonergic
banging 1465
BS, Mann treatment in dementia.
DB, Silverman of screaming Lancet 1986;
SM:
and 2:1464-
2. Simpson DM, Foster 0: Improvement in organically disturbed behavior with trazodone treatment. J Clin Psychiatry 1986; 47:191-193 3. O’Neil M, Page N, Eichelnian B: Trypto-
phan-trazodone
treatment
of aggressive
behavior. Lancet 1986; 2:859-860 4. Pinner F, Rich CL: Effects of trazodone aggressive behavior in seven patients with organic mental disorders. Am chiatry 1988; 145:1295-1296
VOLUME
4
#{149} NUMBER
3
#{149} SUMMER
on
J Psy-
1992
