A 31-year-old man with a 24-year history of therapy refractory TS and a positive family history of tic disorders presented to our center (Figure 3). Tics initially presented at the age of 7 when he developed simple focal motor tics such as eye blinking and soon thereafter displayed vocal tics including hiccups and exaggerated inhalations by the age of 9; In the course of disease tics became more pronounced in intensity and complexity. Vocal tics expanded to spontaneous outbursts of words; motor tics developed into head jerking movements and self-injurious behavior i.e., tongue biting. Symptom progression led case 1 to take drugs at the age of 15 (marijuana), by the age of 18 he had moved on to amphetamines and alcohol in order to relieve symptoms. Case 1 attended vocational technical school to become a cutting machine operator and soon thereafter was retrained as a system technician. Due to work-related stress and accompanying exacerbation of tics, the patient withdrew socially over the course, avoiding social situations such as grocery shopping. He developed panic attacks and reported episodes of rumination. Three years prior to surgery case 1 fell into a depression. Treatment for tics over the years included, among others, tiapride, diazepam, as well as diverse antipsychotics and antidepressants. Neither drug treatment nor behavioral interventions could alleviate tic severity sufficiently and treatment was eventually discontinued due to intolerable side effects.
Upon admission for H1 DBS the patient's medication included tiapride (200 mg/d). Preoperative psychiatric evaluation disclosed a YGTSS score of 79 with an impairment subscore of 40. Depressive symptoms were found to be stable and he was approved for bilateral H1 stimulation.
Postoperatively, case 1 already noticed marked symptom relieve with the stimulator device being turned off ("insertional effect") (Figure 2A). In the course of electrical stimulation he experienced good control of tics, which were self-rated at 60% improvement. He noted considerable improvement of complex tics such as tongue biting and was able to discontinue medications. Case 1 was successfully able to resume work and was promoted to shift supervisor within the following year. Depressive and anxiety symptoms subsided entirely, the patient was able to participate in social situations, and furthermore was expecting a child with his girlfriend. At 1-year follow-up he reported nearly complete relief of his tics with 85-90% symptom alleviation. His YGTSS score had improved significantly and was 7 (impairment subscore, 0; Table 3). Stimulation parameters as adjusted during the follow-up period can be obtained from Table 2.