A clinical condition characterized by multiple, persistent motor and/or vocal tics, present to a variable extent since childhood, was first described in the 19th century. First known as Gilles de la Tourette syndrome, it is now included in DSM-5 as Tourette's disorder. With a prevalence of 3 to 8 cases per 1,000 school-age children, it is more frequent in males; symptoms usually begin between 4 and 6 years of age, worsen in pre-adolescence, and may decline in adolescence.1
Changes in the cortico-striatal-thalamic circuitry2
promote executive dysfunctions, impaired impulse control, and impaired inhibition of undesirable behaviors.3
Anxious factors exacerbate the symptomatology.4
Obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD) are the most prevalent comorbidities and the most important differential diagnoses, along with tourettism (Tourette's-like symptoms secondary to brain injury).
Rarely does Tourette's disorder per se lead to criminal behavior, although comorbidities, anger episodes secondary to obsessive ruminations of intrusive thoughts, and motor (copropraxia, coprography) and verbal (coprolalia) inadequacies may increase this risk.3
There is no lack of empathy as found in antisocial personality. The modest specialized literature concerning the clinical specificities of Tourette's disorder and associated legal issues demonstrates that these patients are frequently found guilty when charged with offenses.3,5,6
We will share our considerations about a case evaluated at Instituto Psiquiátrico Forense Doutor Maurício Cardoso, in Porto Alegre, southern Brazil.
At age 35, the patient was indicted for statutory rape after he impulsively kissed the mouth and caressed the genitals of a neighbor's child in front of the child's mother. During childhood, the patient had exhibited restless and disruptive behavior secondary to impulsivity. From the age of 7, he developed checking and symmetry obsessive-compulsive symptoms and motor tics, which included touching feces; he ultimately received a diagnosis of Tourette's disorder with comorbid OCD. During adolescence, the patient's neuropsychiatric symptoms worsened. He became unable to manage his self-care, began pharmacotherapy (haloperidol), and was hospitalized for dosage adjustments at age 12. The patient had an impoverished relationship life, was somewhat infantilized and dependent on relatives. He denied paraphilias of any order, coprolalia, or psychotic experiences. Currently, he reported obsessive rituals as well as sensory phenomena related to touching: "like an intuition [...]. I usually can't control" (sic
). His involuntary movements, which appeared minimal during the evaluation, were exacerbated when the patient was observed indirectly. He had normal intelligence (IQ 74), had never used illegal substances, and denied any psychiatric or criminal family history.
The patient adequately modulated affect, and endorsed guilt and shame for the offense he had committed. The diagnoses of Tourette's disorder and OCD increased the manifestations of acts that were not necessarily subjugated to volition, making commission of the sexual offense more impulsive and disorganized (committed in the presence of others). This modus operandi is distinct from that of sexual aggressors, whose practices involve premeditation and dissimulation, absence of guilt, and high odds of recidivism. The judge accepted the expert's report, considered the patient not guilty by reason of insanity, and ordered regular outpatient treatment in the community. Identifying the clinical repercussions of Tourette's disorder, as well as understanding its forensic psychiatric implications, can improve referral and treatment and prevent double stigmatization.DISCLOSURE
The authors report no conflicts of interest. REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington: American Psychiatric Publishing; 2013.
2. Hounie A, Petribú K. Síndrome de Tourette - revisao bibliográfica e relato de casos. Braz J Psychiatry. 1999;21:50-63.
3. Comings DE, Comings BG. Sexual abuse or Tourette syndrome? Soc Work. 1993;38:347-50.
4. Jankovic J, Kwak C, Frankoff R. Tourette's syndrome and the law. J Neuropsychiatry Clin Neurosci. 2006;18:86-95.
5. Comings DE, Comings BG. Tourette syndrome: clinical and psychological aspects of 250 cases. Am J Hum Genet. 1985;37:435-50.
6. Wright A, Rickards H, Cavanna AE. Impulse-control disorders in gilles de la Tourette syndrome. J Neuropsychiatry Clin Neurosci. 2012;24:16-27.