Descriptive Psychopathology: The Signs and Symptoms of ...

300 Section 3: Examination domainsparoxysms of profanity, affects a third of patients. Echolalia and echopraxia occurin one-third of patients. 56Behavioral disturbances including hyperactivity and attentional and othercognitive problems, school and social difficulties, classroom disruption, fighting,temper tantrums, and mood swings are reported in half of GTS sufferers. Thepattern may lead to the mistaken diagnosis of manic-depression. A small proportionof GTS patients meet criteria for antisocial personality disorder, exhibitsexually inappropriate behavior (e.g. compulsively groping or commenting), areaggressive and assaultive, and cruel to animals and peers. Phobias occur in 20%of GTS patients.Sleep disturbances are common in patients with GTS, and include initialinsomnia, talking during sleep, nightmares and night terrors, somnambulism(sleep walking), and bruxism (teeth grinding). Up to a third are enuretic.Pediatric autoimmune neuropsychiatric disorder associatedwith Streptococcus infection (PANDAS) 57Beta-hemolytic streptococcal A infection may be associated in the followingtwo months with the rapid emergence of PANDAS, particularly in patients whoearly on in the infection develop chorea or tics. Boys aged 6–7 years, often with afamily history of autoimmune disease (e.g. Grave’s disease, rheumatoid arthritis)are most often affected. Symptoms include GTS features, Sydenham’s chorea,squirming and fidgeting that can be mistaken for ADHD, anorexia nervosa, andmood disturbances. High levels of antineuronal antibodies leading to striatalinflammation and the MRI finding of enlarged striatal volumes confirm thediagnosis. While most patients fully recover, some become chronically ill, asillustrated by Patient 12.1.Patient 12.1A 17-year-old boy with a history of Asperger’s syndrome and migraine waspsychiatrically hospitalized because of worsening OCD symptoms and thedevelopment of catatonia. He recently stopped eating, losing 15 lbs in thetwo weeks prior to admission. He spent hours ritually touching certain objectsin a certain sequence. He stood for long periods staring. He stopped doing hisschool work and engaging in his interests. He complained of his migraineheadaches worsening during this period.On admission, his muscle tone was increased and he could be postured,briefly retaining the new position. He exhibited automatic obedience andGegenhalten. His speech was minimal, prosectic and he had echolalia. Lorazepamdid not relieve his catatonia. He received 19 bilateral ECT which didrelieve the catatonia, and he was discharged on valproic acid and alprazolam. 58