Post-Operative Adult Onset Tic Disorder: A Rare Presentation

By Upadhyaya, Suneet; Raval, Chintan et al. | Indian Journal of Psychological Medicine, October-December 2014 | Go to article overview

Post-Operative Adult Onset Tic Disorder: A Rare Presentation


Upadhyaya, Suneet, Raval, Chintan, Sharma, Devendra, Vijayvergiya, Devendra, Indian Journal of Psychological Medicine


Byline: Suneet. Upadhyaya, Chintan. Raval, Devendra. Sharma, Devendra. Vijayvergiya

Tics are rapid and repetitive muscle contractions resulting in stereotype movements and vocalizations that are experienced as involuntary. Onset before 18-year is a diagnostic criterion for tic disorders. Children and adolescents may exhibit tic behaviors after a stimulus or in response to an internal urge. Tic behaviors increase during physical or an emotional stress. Adult onset tic disorders are reported by infections, drugs, cocaine, toxins, chromosomal disorders, head injury, stroke, neurocutaneous syndromes, neurodegenerative disorders and peripheral injuries. Only few cases have yet been reported having onset after surgery though surgery brings both physical and emotional stress to the patient. We report a case of a 55-year-old lady who developed tic disorder as post-operative event of cataract surgery. Our patient had a dramatic response to haloperidol which is in contrast to all earlier reports.

Introduction

Tics are sudden, rapid, recurrent, non-rhythmic, stereotyped movements or vocalizations that are experienced as involuntary. Tic disorders is usually present in childhood or adolescence. [sup][1] Tic disorders presenting during adulthood have infrequently been described in the medical literature, mostly in relation to neurological disorders. [sup][2] Adult onset tic disorders are considered as persistence of tics from childhood with the assumption that patients cannot remember having childhood tics. [sup][3] Various reports depict the adult onset tic disorders caused by infections, drugs, cocaine, toxins, chromosomal disorders, head injury, stroke, neurocutaneous syndromes, neurodegenerative disorders. [sup][4] only few cases have been linked to surgeries [sup][5],[6] and peripheral injuries. [sup][7]

Here we report a case of tic disorder developing after cataract surgery, which showed a dramatic response to haloperidol in contrast to earlier reports of adult onset tic disorders.

Case Report

A 55-year-old uneducated widow presented by her son with the complaints of abnormal facial movements and slurring of speech to the out-patient Department of Psychiatry and she had right eye cataract surgery with implantation of intraocular lens 1 year back. After the surgery, she felt dryness and itching in eyes which was resolved with the use of artificial tears for 1 month. After 2 weeks itching and pain of the face and neck restarted along with movements, which gradually increased. Her facial tics were frequent, although movements free periods of few hours were not uncommon. Son reported her irritability and decreased frustration tolerance in those days. As her movement increased, she started showing a non-gregarious nature spending an appreciable time in reclusion.

On examination, she had eye blinking, mouth twitching, facial grimacing, lip pouting, lip licking, chewing on the lip, irregular tongue movements and lower jaw protraction. With hard effort she was able to partially suppress her movements for 5-10 s. No other vocal or motor tics were found in enquiry or examination. Her speech slurring was due to tongue movements and was suppressible for few seconds and even more when distracted from the topic of her illness. She was never found to scratch her face or eyes. Examination by Ophthalmologist and Dermatologist didn't reveal any problem in eyes or face respectively.

There was no history of intellectual decline. She denied history of symptoms suggestive of tics, attention deficit disorder, obsessive-compulsive disorder, impulse control disorder or any other psychiatric illness. There was no history of prolonged drug intake, head injury, seizure, chorea, dystonia or any other involuntary movement disorder. There was no history suggestive of pre morbid personality traits of obsessive, histrionic, narcissistic, antisocial or borderline type.

Patient was a chronic tobacco smoker who had a problem of acidity for last 8 years, which restricted her to bland foods. …

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