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Ask the Mental Health Expert Archives 2001-2004

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Faking Tourette's

Q. I work in a group home for mentally retarded adults. There is a 43-year-old mildly mentally retarded patient who was diagnosed with Tourette's Syndrome at an early age. I am beginning to doubt his diagnosis.

He doesn't have many tics, occasionally he might have a sudden sway in his arm. When he curses someone, it's more an emotional outburst than an uncontrollable behavior. He threatens people, pinches, kicks and throws things. Some days are better than others, but there isn't a single person he hasn't been aggressive towards, either verbally or physically. He is very apologetic at times, but will continue this behavior while he apologizes.

He is on several medications and one is for when he is just unable to accept re-direction. Once given this medication, he instantly stops the abrupt behavior. I think he is very demanding and spoiled. There are no consequences for this abuse so it just continues.

Is there a condition that describes this person a little better than Tourette's?

A. I can't really offer diagnostic or treatment advice without seeing the patient, of course, but here are some issues to consider. First of all, I think you are wise to raise questions about the diagnosis. Certainly, Tourette's Syndrome (TS) may be one factor underlying this individual's behavior, but it might not be the only one.

For example, one study (Budman et al, Acad Child Adolesc Psychiatry 2000;39:1270-6) examined "explosive outbursts" in children diagnosed with TS. The authors found that children with TS and explosive outbursts were very likely to have co-morbid conditions, such as Attention-deficit hyperactivity disorder and obsessive-compulsive disorder. Oppositional Defiant Disorder was also seen in many subjects. Explosive outbursts did not seem to be related to tic severity or type. Indeed, most pure TS individuals do not show markedly aggressive or explosive behavior. Undiagnosed bipolar disorder may also present as violent or aggressive outbursts.

Thus, the first step is a complete neuropsychiatric re-assessment. Then, an examination of the patient's medications can take place. Some medications, such as benzodiazepines, may actually dis-inhibit this type of individual, while other medications (such as lithium, beta blockers, or anticonvulsants) may reduce aggressive outbursts. And if, as you suggest, there really are no consequences to this person's aggressive behavior, he is, indeed, likely to continue behaving in this way. Thus, a strict program of behavioral therapy may be required to turn things around. This does not mean punishing the person; but rather, building a foundation of rewarding and non-rewarding consequences for his behaviors. A behavioral psychologist would probably be in the best position to provide this kind of consultation.

Good luck!

April 2002

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