Transcranial magnetic stimulation in Tourette Syndrome with obsessive-compulsive disorder and regional brain metabolism (18FDG PET): A case report
Abstract
We report the successful treatment of a patient with comorbid Tourette syndrome (TS) and OCD, using repetitive transcranial magnetic stimulation (rTMS) in addition to stable chronic medication and cognitive behavioral therapy (CBT). The patient was examined using 18FDG PET in order to detect changes in the regional brain metabolism before and after the treatment.
Data were analysed using SPM99 and compared with healthy population (N=7, men, mean age=31.1, SD=+-5.9). 1 Hz rTMS was applied in 10 sessions, at 100% of the motor threshold, over the left dorsolateral prefrontal cortex, with 1800 impulses in single train. CBT was performed in a group setting (3 times per week) with additional individual sessions during the 6-week period.
Psychopathology was assessed by CGI, Y-BOCS and self-constructed rating scale for tics. After the treatment, there was a robust clinical improvement in tics, obsessions and compulsive behaviour.
We have detected changes in the regional brain metabolism corresponding to the proposed neurobiology of TS. An increased metabolism was found in the putamen, Broca's area, superior temporal gyrus and insula in the right hemisphere, in the left parahippocampal gyrus, amygdala and claustrum, and bilaterally in the posterior cingulate, pre- and postcentral gyrus and parietal cortex.
Decreased metabolism was detected in the right prefrontal cortex and anterior cingulate cortex bilaterally. After the treatment, a trend for normalisation of the hypermetabolism was found in regions with an increased uptake of 18FDG.
We assume that both treatment modalities influenced the symptoms. The results are concordant with the proposed effect of low frequency rTMS and also might be attributed to the effect of CBT.
In treatment resistant patients suffering from TS and OCD comorbidity, a combination of treatments should be considered.