Hormonal response to dehydroepiandrosterone administration in schizophrenia: findings from a randomized, double-blind, placebo-controlled, crossover study.
To the Editors: Meanwhile, there are several case reports and series on the use of the partial dopamine (DA) receptor agonist aripiprazole in children, adolescents, and adults with Tourette syndrome (TS) or obsessive-compulsive disorder (OCD). The results of these reports are encouraging in showing that aripiprazole may indeed reduce both TS and OCD symptoms in patients refractory to other therapeutic options. Yet, the inconsistency in the demonstration of beneficial effects in TS and predominantly OCD and the variability in the dosages needed to obtain a therapeutic effect highlight the necessity of double-blind studies investigating the therapeutic efficacy of aripiprazole. The following case may promote the endeavor to undertake such approach. Mrs K developed various motor and phonemic tics since the second decade of her life and was diagnosed with TS according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria in her early twenties. She further had obsessionality from early teenage, which, in accordance with Diagnostic and Statistical Manual of Mental Disorders, had progressed to OCD over the years. In addition, the patient had self-injuring behavior. Since diagnosis, she received different pharmacological treatments, including haloperidol, clozapine, amisulpride, sulpiride, clomipramine, amitriptyline, and paroxetine, all of which were taken in adequate dosages and for adequate periods. Also, she followed several psychotherapies. Both therapeutic approaches had only marginal effects. If anything, symptoms improved for only a few weeks after the onset of a new drug. This, however, was accompanied by side effects, mainly sedation. Mrs K was referred to us for expert management because symptoms have even worsened in the course of private problems. At admittance, Mrs K’s mental state and neurological examinations were normal apart from her tics and OCD symptoms. During the examination, she presented with Bher typical set of tics[ comprising simple and complex motoric tics as expressed in frowning, eyebrow raising, grimacing, head-neck turns, shoulder shrugging, arm jerking, foot and leg movements, tic-alike compulsive touching, and apparently goal-oriented whole body movements as well as copropraxia. Vocalizations included simple vocal symptoms as well as coprolalia, echolalia, blocking symptoms, and articulation of words and whole sentences describing or commenting the situation. When being asked for OCD symptoms, she only hesitantly and ashamedly reported a strong impairment occupying herself up to 8 hours a daywith only short symptomfree intervals. Symptoms comprised aggressive obsessions, violent or horrific images, fear of blurting out obscenities or insults, obsessions with the need for symmetry and exactness, miscellaneous obsessions, repeating rituals and checking compulsions, as well as ordering or arranging compulsions. Mrs K’s rating scores were as follows: Yale Global Tic Severity Scale (YGTSS): 19 (motor)/22 (phonic)/40 (global) [instrumental range 0–25 (motor)/0–25 (phonic)/0–50 (global impairment)]; Yale-Brown ObsessiveCompulsive Scale (Y-BOCS): 15 (obsessions)/19 (compulsions) (instrumental range, 0–20 for each obsessions and compulsions); Tourette syndrome (selfrating) symptom list (TSSL): 39 (simple motor)/30 (complex motor)/11 (simple phonic)/26 (complex phonic)/58 (behavior) (instrumental range, 0–55 simple motor tics)/0–60 (complex motor tics)/ 0–35 (simple phonic tics)/0–40 (complex phonic tics)/0–90 (global behavior). We suggested that she stopped paroxetine (20 mg/d), which she was intermittently taking at that time, but to continue with lopinavir, lamivudine, zidovudine for further 1.5 months, which she was taking in the context of a precautionary measure. We started to prescribe aripiprazole at a dose of 5 mg/d as long as she was on antiretroviral combination therapy and thereafter increasedup to10mg/d to come back to a final dose of 7.5 mg/d. We saw her on a biweekly cycle. Even 2 weeks after the onset ofmedication, she reported that her tics and OCD symptoms had dramatically improved. This effect remained stable even in stress situations and persisted until the final observation time point, 6 months after onset of the treatment (BI have not felt like that for the last 24 years[). She reported no side effects. On rating scales, her scores reduced by the following percentages: YGTSS, 42% (motor)/36% (phonic)/ 50% (global); Y-BOCS, 53% (obsessions)/68% (compulsions); TSSL, 33% (simple motor)/47% (complex motor)/ 18% (simple phonic)/46% (complex phonic)/60% (behavior); and to the following scores: YGTSS, 11 (motor)/14 (phonic)/20 (global); Y-BOCS, 7 (obsessions)/6 (compulsions); TSSL, 26 (simple motor)/16 (complex motor)/9 (simple phonic)/14 (complex phonic)/23 (behavior). In summary,MrsK’s improvement in all symptoms checked after aripiprazole was profound. The present case adds and complements to previously reported data on the use of aripiprazole in TS and/or OCD (Table 1). As summarized in Table 1, 17 of the 18 so far reported adults and 18 of the 23 reported children and adolescents showed a decrease in Tourette symptom severity. Similarly, 6 of the 12 reported adults and 6 of the 7 reported children and adolescents with comorbid or TSindependent OCD showed a decrease in OC symptoms under aripiprazole (augmentation) therapy. Notably, there was an induction of OCD symptoms demonstrated in 2 OCD-naive patients, and all together 7 of 11 single cases showed a successful reduction of comorbid OCD in patients experiencing TS. These discrepancies in the clinical outcome might be Letters to the Editors