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To the Editor: Akinetic mutism is a pathological condition characterized by lack of spontaneous movements with little or no vocalization in subjects with intact corticospinal pathways. 1 This condition was first described in patients who suffered diencephalic damage, and current evidence indicates that it is a transient state resulting from lesions that interfere with reticular/cortical integration. 2 We present a rare case of persistent akinetic mutism after bilateral paramedian thalamic infarction.

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Self injurious behavior, i.e. the deliberate, non-accidental, repetitive infliction of self harm, has been reported in a wide range of neuropsychiatric conditions. Clinical and epidemiological studies have shown that self-injurious behavior can occur in up to one third of patients with Gilles de la Tourette syndrome, a neurodevelopmental disorder, characterized by the presence of multiple motor tics and at least one vocal/phonic tic. This paper describes the case of a patient diagnosed with Gilles de la Tourette syndrome who presented with severe multiple self injurious behaviors since early childhood. On physical examination, we documented a few self-injurious behavior signs including scars in the forehead resulting from repetitive head-banging and bald patches on the scalp due to trichotillomania. Characteristically, self-injurious behaviors were distressing and resistant to treatments (both pharmacotherapy and cognitive behavioral therapy), and were associated with comorbid obsessive-compulsive disorder. This case illustrates the complex nature and difficult management of severe self-injurious behavior in the context of Gilles de la Tourette syndrome and obsessive-compulsive disorder.

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