Gilles de la Tourette's syndrome successfully treated with electroconvulsive therapy.

Sir,

Gilles de la Tourette syndrome (GTS) is neuropsychiatric disorder. Pharmacological interventions are widely used and have proven efficacy. Electroconvulsive therapy (ECT) is rarely used and can be considered as an alternative treatment modality.

A 30-year-old female was brought by her relatives with the complaints of abnormal involuntary movements of right upper, lower limbs and of lips (motor tics), which were stereotyped, sudden, jerky, and nonrhythmic associated with premonitory urge. She also had repetitive throat clearing sounds (vocal tics), repetition of obscene words (coprolalia). Tics were insidious in onset and gradually progressive since last 18 years. She also had senseless, repetitive, persistent, intrusive, distressing thoughts that something catastrophic is going to happen to her family members since last 12 years. There was no past and family history of any psychiatric illness.

All her laboratory investigations were within normal limits. Rheumatoid arthritis factor, antistreptolysin O titres were negative. Magnetic resonance imaging brain and electroencephalogram were within normal limits. Her score on Yale-Brown obsessive compulsive scale (YBOCS) was 25/40 and Yale global tic severity scale (YGTS) was 84/100.

She had a poor response to oral haloperidol 3 mg/day, risperidone 4 mg/day and tetrabenazine 50 mg/day, fluoxetine 60 mg/day for 12 weeks and developed extra pyramidal side effects. Hence ECT was considered as an alternative treatment. She was given six ECTs on alternate days under general anaesthesia. She improved significantly after the course of ECT. Her obsessive ruminations remitted completely. YBOCS score decreased to 0. The tics decreased in severity (YGTS score decreased to 3/100). The patient followed-up for 3 months and maintained improvement till then.

Electroconvulsive therapy is rarely used in patients with GTS. Literature review reveals few case reports about use of ECTs in GTS. Karadenizli et al.[1] studied ECT in a patient of GTS with self-injurious behaviour. Two years of complete remission was achieved in tics and self-injurious behaviour after 7 sessions of ECT and carbamezapine maintenance therapy. Dehning et al.[2] studied long-term results of ECT in severe GTS with self-injurious behaviour where there was full remission of vocal and motor tics as well as self-injurious behaviour. Maintenance ECTs were given for persistent premonitory urge for a period of 5 years. The patient remained symptom free for 5 months after stopping ECTs. Rapoport et al.[3] reported a case of response of major depression and Tourette's syndrome to ECTs. He found that woman with preexisting TS, which had been latent during her adult life, re-emerged with the onset of her major depression, and both symptoms resolved fairly after ECTs. Strassnig et al.[4] used ECT in a patient of GTS with co-morbid refractory OCD. After the course of nine ECT treatments, grimacing and oral hyperkinesias, lip and tongue biting, tongue protrusion and spreading of fingers had completely ceased. Obsessions and compulsions were absent. Mild shaking of upper limbs continued.

Similarly our patient had remission with ECT. ECT is a safe an effective treatment option along with pharmacotherapy for cases of GTS not responding to pharmacotherapy.