Psychosurgery for Self-Injurious Behavior in Tourette's Disorder

Abstract

One of the most serious and difficult-to-treat conditions in child and adolescent psychiatry is self-injurious behavior (SIB). SIB can be associated with a number of psychiatric disorders, including mental retardation, schizophrenia, borderline personality disorder, pervasive developmental disorders, stereotypic movement disorder, and Tourette's Disorder. A variety of neurosurgical procedures have been used to treat both intractable SIB and severe Tourette's Disorder. Understandably, there are few reports concerning psychosurgery in children and adolescents for any condition or disorder. This report describes the use of cingulotomy and subsequent limbic leucotomy in an adolescent boy with Tourette's Disorder for SIB. His repetitive and medically serious SIB and failure of all other treatments prompted this intervention after careful, comprehensive review and discussion. Following the second surgery, the severity and frequency of his SIB were reduced.

Neurosurgical strategies for Gilles de la Tourette’s syndrome

“…Targeting the cingulate cortex for the treatment of TS seemed appropriate given its recognized role in mediating emotional experiences and language and coordinated movements (Robertson et al 1990). Cingulotomy decreased tics by 75% by 2 years post-operatively in one patient (Anandan et al 2004) and provided enduring improvement in another (Sawle et al 1993). In an imaging study that found normalization of preoperative hypermetabolism in the caudate nucleus and thalamus, the beneficial effects of cingulotomy were ascribed nonspecifically to the disruption of abnormal basal ganglia-thalamocortical circuitry (Sawle et al 1993).…”

“…Simple TS is characterized by the predominance of motor and vocal tics, whereas more complex subtypes feature coprolalia, copropraxia, echolalia, echopraxia, palilalia, and/or palipraxia (Robertson et al 1990; Jankovic 2001). Patients with TS may also commonly exhibit other behavioral symptoms (Gilbert 2006), such as attention deficit-hyperactivity disorder (Robertson 2000), obsessive compulsive disorder (Frankel et al 1986; Como 1995), self-injurious behaviors (Robertson et al 1989; Kurlan et al 1990; Leckman et al 1993; Houeto et al 2005; Anandan et al 2004; Ackermans et al 2007), and/or anxiety disorders (Robertson 2000). …”

“…The association of tics with medical or psychiatric conditions may necessitate more aggressive tic management. For example, TS has been associated with self-injurious behaviors requiring urgent medical attention (Robertson et al 1989; Kurlan et al 1990; Leckman et al 1993; Houeto et al 2005; Anandan et al 2004; Ackermans et al 2007), such as corneal and orbital injuries (Robertson et al 1990) and stab wound- inflicted injuries (Anandan et al 2004), or tic-induced medical complications, such as cervical myelopathy (Krauss and Jankovic 1996), limb fractures, and retinal detachments (Flaherty et al 2005). The variety of medications used to manage TS has included dopaminergic antagonists, benzodiazepines, calcium channel antagonists, and atypical neuroleptics (Kurlan 1997; Robertson and Stern 2000; Jiménez-Jiménez and García-Ruiz 2001; Müller-Vahl 2002).…”

Contingent Skin-Shock Treatment in 173 Cases of Severe Problem Behavior

“…Primary treatments include psychopharmacological interventions, function-based behavioral interventions, and various forms of restraint and protective equipment. In addition, electroconvulsive therapy (ECT) [5,6], deep brain stimulation [7], and psychosurgery [8] have been utilized.…”

Deep brain stimulation of the nucleus accumbens and the internal capsule in therapeutically refractory Tourette-syndrome

“…On the basis of experiences whereby lesional neurosurgical interventions have, in individual cases of TS, lead to positive developments, DBS has recently gained in status as an experimental form of therapy in the treatment of patients suffering from TS [2,14,16]. According to our research of the literature, eight cases of TS having been treated with DBS have been reported [1,5,6,10,17].…”