QUESTION 1

A mother brings her nine-year-old son to see you worried about his behaviour. He has been constantly blinking, shrugging his shoulders with occasional inappropriate clapping or whistling. He has also started swearing uncontrollably in public and in class.

When challenged about his behaviour he says that he is unable to control it. He has no past medical history of significance, and the only significant family history is obsessive compulsive disorder in an older sister.

What is the SINGLE MOST likely diagnosis? 

1. Frontal lobe space occupying lesion

2. Emotionally unstable personality disorder

3. Tourette syndrome

4. Bipolar affective disorder

5. Schizophrenia

Tourette syndrome involves motor and vocal tics. The typical age of onset is six-seven years old. Tourette syndrome has strong genetic association with obsessive compulsive disorder. With this association, there is often a family tendency for male relatives to have tic disorders and for female relatives to be affected by obsessive compulsive disorder. Diagnostic criteria for Tourette syndrome include:

• Multiple motor and one or more vocal tics at some point in illness

• May wax and wane but have persisted over one year

• Onset before the age of 18

Not caused by substance or other condition.

QUESTION 2

A 16-year-old with Tourette syndrome has been experiencing worse tics over the past few months. They have become debilitating and are affecting his life both at home and school.

What is the SINGLE licensed medication to treat his condition?

1. Olanzapine 

2. Diazepam

3. Risperidone 

4. Haloperidol 

5. Sulpiride

Haloperidol is the only licensed medication to treat tic disorders. Although haloperidol reduces the tic severity significantly, extrapyramidal side effects limit the dosage. Treatment may continue for 1–2 years or longer if symptoms persist. Whilst other medications like sulpiride and pimozide may show better efficacy or have more favourable side effects compared to haloperidol, these are currently off license for tic disorders.

Reference

• Poulter C, Mills J. Tourette syndrome and tic disorders. InnovAiT 2018; 11(7): 362–365.