A 20-year-old college student comes to the office due to worsening abnormal movements. The symptoms initially started in middle school when he would repeatedly blink and then shrug his shoulders. The patient worked with a counselor who taught him techniques to suppress movements for periods of time, although these did not completely resolve them. Over the past few years, the symptoms have gradually worsened. Episodes now occur multiple times daily, particularly around highly stressful times at school. His grades have declined, and he is embarrassed during class presentations. The patient has no history of serious illness and takes no medications. He occasionally smokes marijuana on weekends. Family history is notable for the death of his father at age 50 from a stroke. Vital signs are normal. During the examination, the patient is visibly anxious. He repeatedly blinks, clears his throat, and shrugs his shoulders. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate treatment for this patient?

Question

A 20-year-old college student comes to the office due to worsening abnormal movements.  The symptoms initially started in middle school when he would repeatedly blink and then shrug his shoulders.  The patient worked with a counselor who taught him techniques to suppress movements for periods of time, although these did not completely resolve them.  Over the past few years, the symptoms have gradually worsened.  Episodes now occur multiple times daily, particularly around highly stressful times at school.  His grades have declined, and he is embarrassed during class presentations.  The patient has no history of serious illness and takes no medications.  He occasionally smokes marijuana on weekends.  Family history is notable for the death of his father at age 50 from a stroke.  Vital signs are normal.  During the examination, the patient is visibly anxious.  He repeatedly blinks, clears his throat, and shrugs his shoulders.  The remainder of the physical examination shows no abnormalities.  Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d5d0_f1aa_bc81_9fbe19fa2a33_MD0003_00 This patient's presentation is most consistent with Tourette syndrome (TS). TS, a neurological disorder with childhood onset, is characterized by a combination of vocal (eg, throat clearing) and motor (eg, blinking, shoulder shrugging) tics. Tic severity typically peaks at age 10-12, and tics are exacerbated by anxiety, fatigue, and psychosocial stress. When tics are severe and debilitating (eg, declining academic performance, psychosocial dysfunction), as in this patient, treatment options include behavioral suppressive therapy (eg, habit reversal training, substituting a voluntary movement incompatible with the tic) and pharmacological interventions. Pharmacotherapy of TS consists of: Antidopaminergic drugs: Vesicular monoamine transporter type 2 (VMAT2) inhibitors (eg, tetrabenazine) function as dopamine depleters, whereas antipsychotic medications (eg, risperidone) block dopamine postsynaptic receptors and carry risks of parkinsonism, tardive dyskinesia, and metabolic effects. VMAT2 inhibitors are therefore increasingly preferred as initial treatment over antipsychotics. Alpha-2 adrenergic receptor agonists (eg, guanfacine, clonidine) can be considered in patients with comorbid attention deficit hyperactivity disorder or behavioral symptoms. (Choice A) Antisense oligonucleotide therapy is an investigational treatment for Huntington disease (HD), a progressive neurodegenerative disorder characterized by choreiform movements and neuropsychiatric symptoms, including dementia. However, it is an inherited condition (eg, family history of progressive motor and cognitive decline) that is most common in midlife, with diagnosis prior to the age of 20 being rare. In addition, this patient's partial response to behavioral suppressive therapy in middle school makes TS more likely than HD. (Choice B) Copper chelation therapy is used in the treatment of Wilson disease, an autosomal recessive disorder that presents with hepatic, neurologic, and psychiatric symptoms. Neurological manifestations commonly include dysarthria, dystonia, ataxia, parkinsonism, and drooling, rather than the waxing and waning tics seen in this patient. In addition, this patient has no hepatic impairment, making TS the more likely diagnosis. (Choice C) The GABA agonist medication clonazepam (a benzodiazepine) is a first-line treatment option for myoclonus; this patient's motor and vocal tics are consistent with TS rather than myoclonus. (Choice D) Serotonergic drugs (eg, selective serotonin reuptake inhibitors) would not effectively target this patient's tics. These medications may help treat patients with TS who have comorbid anxiety or obsessive-compulsive disorder. Educational objective: Pharmacotherapy of Tourette syndrome consists of vesicular monoamine transporter type 2 (VMAT2) inhibitors, antipsychotic medications, and alpha-2 adrenergic receptor agonists. VMAT2 inhibitors are increasingly preferred as initial treatment over antipsychotics due to a more favorable adverse effect profile. References: Practice guideline recommendations summary: treatment of tics in people with Tourette syndrome and chronic tic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/31061208)

A 20-Year-Old College Student Comes to the Office Due to Worsening