LETTERS

observed

by the

examiners.5

Even

patients who recognize their tic disorders often underestimate the number and frequency of tics that are actually

observed

by physicians.

Despite these phenomenologic and mechanistic perplexities, our experience suggests that some patients

with

TS may

develop

psycho-

diagnosis should be considered for TS patients when an unusual and resistant tic pattern appears, particularly after a period of good pharmacologic control and in patients with personality and emotional disturbances. The recognition of this phegenic

This

pseudo-tics.

nomenon

may

be important

of patients with ROGER KuiIAr’, M.D. CHERYL DEELEY, R.N., M.S. PETER G. CoMo, PH.D. Department of Neurology, University

CASE

of Rochester

This patient

depressive,

movement

disorders.

5:127-133 2. Fahn S: The

tics, in Gilles

Mov

clinical spectrum de is Tourette

by Fnedhoff

A: PsychoDisord

1990;

of motor Syndrome,

AJ, Chase

11:559-564

4. Lang A: Patient other movement 1991;

perception disorders.

of tics and Neurology

41:223-228

5. Kurlan

R, Behr J, Medved L, et al: Severity of Tourette’s syndrome in one large kindred: implication for determination of disease prevalence rate. Arch Neurol 1987;

44:268-269

Trazodone Treatment Targeted Aggression Mentally Retarded

of in a Man

SIR: Aggressive behavior is a symptom that occurs in a number of neuropsychiatric disorders, including dementia and mental retar-

348

or psychotic

episodes.

He

instances. ed-

TN. New Raven, 1982, pp 341-344 3. Lichter D, Majumdar L, Kurlan R: Opiate withdrawal unrnasks Tourette’s syndrome. Clin Neuropharmacol 1988; ited York,

a

had been treated with a variety of neuroleptics in the past without success. One month prior to referral, he was caught lying in wait with matches and aerosol spray, with a plan to set afire a female staff member whom he had been following and harassing. Since that time he continued to stalk her whenever possible and attempted aggressive physical contact with her in a number of

NY

organic

of aggressive

carried

tal retardation of impulsive aggression, induding assaults and suicide attempts involving hanging, wrist cutting, and head banging. This was in the setting of chronic affective lability without sustained manic,

TS.

with

acting out. diagnosis of menand had a 15-year history

management

References 1. Ranawaya R, Riley 0, Lang genic dyskinesias in patients

inmate in a correctional was referred for pharmacologic

facility

School

Rochester,

REPORT

A 33-year-old

in the

management

of Medicine,

dation. We here report the efficacy of trazodone (Desyrel), a drug useful in treating impulsive aggression in neuropsychiatric patients) in ameliorating planned targeted assaultive aggression in a patient with mental retardation.

Medication regimen at time of evaluation consisted of trifluoperazine 5mg po bid and diphenhydraniine 50mg po bid. Physical

exam

revealed

choreoathe-

toid movements consistent with tardive dyskinesia, but the remainder of the neurologic exam was nonlocal. Mental status exam was remarkable for tangential and mildly pressured speech, euthymic mood but labile affect, and a lack of suicidal ideation or formal thought disorder except for the persistent preoccupation noted above. The patient related a number of assaultive plans to punish the staff member for her inattention.

Cognitive testing revealed impaired fund of knowledge, attention, and concentration consistent with mild to moderate mental retardation. Laboratory values including complete blood count, electrolytes, liver and thyroid function tests, heavy metal screen, and sedimen-

tation

rate were all normal

serum

creatinine

except

of 1.7 mEq/dl

for a and

a

urinalysis revealing proteinuria and hematuria. (Subsequent urologic workup revealed nephrolithiasis.) The patient was diagnosed as mildly mentally retarded with associated organic personality disorder and episodes of targeted aggression. It was decided to treat the patient with trazodone 100mg po ha. After 1 week he was noted to be less affectively labile and more cognitively focused, and he had stopped harassing the staff member. By week 2 the patient had obtained a job sweeping up in the unit, the first time he had ever held a job in prison. Six weeks after initiation of trazodone he had only one aggressive outburst (compared to two a week previously), and trifluoperazine had been reduced to 5 mg qd without untoward behavioral effect. Harassment

of the staff member had completely stopped. Three months after consultation, he remains euthymic, cent episodes of planned assault. Trazodone has ful in the treatment gressive

and

been reported useof impulsive-ag-

self-injurious

in the populations We

believe

with no reor unplanned

this

behavior

noted

above.

to be the

first

re-

ported instance of cessation of planned and targeted aggressive behavior in a patient treated with trazodone. These findings await replication. LAWSON BERNSTEIN, M.D. Western Psychiatric Institute and Clinic and Department of Corrections, State of Pennsylvania

References 11. Greenwald Serotonergic

banging 1465

BS, Mann treatment in dementia.

DB, Silverman of screaming Lancet 1986;

SM:

and 2:1464-

2. Simpson DM, Foster 0: Improvement in organically disturbed behavior with trazodone treatment. J Clin Psychiatry 1986; 47:191-193 3. O’Neil M, Page N, Eichelnian B: Trypto-

phan-trazodone

treatment

of aggressive

behavior. Lancet 1986; 2:859-860 4. Pinner F, Rich CL: Effects of trazodone aggressive behavior in seven patients with organic mental disorders. Am chiatry 1988; 145:1295-1296

VOLUME

4

#{149} NUMBER

3

#{149} SUMMER

on

J Psy-

1992