Behavior therapy for Tourette syndrome

Compiled by Kevin J. Black, M.D. (June, 1999; updated 2001, 2003, 2011, 2012 and most recently September, 2014)

  • Names
    • Habit Reversal Therapy (circa 1973)
    • CBIT = Comprehensive Behavioral Intervention for Tics (named circa 2003) -- more or less HRT in new clothes
  • Overview
    • a behavior therapy treatment for tics
    • A recent review is found in Capriotti et al., 2014
    • qualifies as a "well-established" treatment for TS under American Psychological Association guidelines (Chambless et al., 1998; Cook & Blacher, 2007)
    • recommended by several experts as the first treatment for many TS patients (Verdellen et al., 2011; Steeves et al., 2012; Leckman, 2014)
    • substantial reduction in tics often seen after first session
    • careful observation shows no evidence of substitution of one tic for another, and treatment effects are observed both at home and in the clinic
    • 4 main components as originally described
    • probably the only essential components are Awareness Training and Competing Response Training (Woods et al 1996)
    • an early study used about 20 sessions per year; only 10 sessions were used in the two recent, large, randomized controlled trials (see next section)
  • Evidence for efficacy
    • a very careful randomized controlled trial (RCT) of 10 weeks of standardized CBIT in 126 children with DSM-IV Tourette's Disorder or Chronic Tic Disorder showed clear evidence for superior efficacy of CBIT to a placebo therapy, with effect size of 0.68 for the YGTSS Total Tic Score (effect size was 0.30-0.64 for other outcome measures); 52.5% of children in the CBIT group were rated as "much improved" or "very much improved," versus 18.5% in the control group, for a number needed to treat (NNT) of only 3 (Piacentini et al 2010)
      • this is one of the largest RCTs ever for any treatment for tics! (as of 7/2011, the only larger RCT focused primarily on anti-tic efficacy was a 2008 Chinese study on a clonidine skin patch; two other studies with N=148 and N=136 subjects reported outcome data on tic severity but were primarily ADHD treatment studies in children with tics)
      • the benefit occurred almost entirely in the domain of tics, not in general psychological functioning (Woods et al 2011)
    • a companion RCT in 122 adults with TS (Wilhelm et al 2012) showed a significantly larger decrease in YGTSS scores (effect size = 0.57) and a significantly higher response rate (NNT = 5) in the CBIT group compared to the placebo treatment, which consisted of psychoeducation and supportive therapy (PST). This study was helpful in including follow-up data: at 6 months, 15 of the 24 patients who improved with CBIT during the RCT returned for follow-up, and 12 of the 15 (80.0%) showed continued benefit.
    • there are a number of other less rigorous studies and detailed case reports / small series:
      • one study randomly assigned 10 subjects with DSM-IV Tourette syndrome to active treatment or a wait list; the immediate treatment group had significantly better response at the end of the wait period (Mann-Whitney U test, 1-tailed p<0.025), which persisted (~90% reduction in tics after 12 months); the group that started after 3 months of wait list remained stable until treatment began, then improved rapidly to similar levels; importantly, "the subjective urge to perform the tic was reported by the present subjects to have been greatly reduced or absent" (Azrin & Peterson 1990)
      • a pre-DSM-IV study randomly assigned 22 subjects with neurologist-diagnosed tics to habit reversal or massed practice; the treatments differed significantly (p < 0.001 by ANOVA); the HRT group had 97% reduction in tics at 18-month follow-up with 80% of patients tic free (Azrin et al 1980)
      • a large RCT randomly assigned patients with chronic tic disorders to active treatment with HRT (N=47) or to a wait list control group (N=22); a treatment manual was used; wait-list and active treatment groups differed significantly in mean self-reported tic scores at the end of the wait list period (p < 0.001) and after 4 months (wait list, 21 + 31; active treatment, 7 + 16). At 2-year follow-up, 52% rated tics as "75-100% controlled"; ratings of patient videos and ratings by a friend or family member gave similar results (O'Connor et al 2001; O'Connor 2001, 2003)
      • in 2003, Wilhelm and colleagues reported a randomized controlled study of habit reversal therapy (HRT) versus supportive psychotherapy (intended to serve as a control) in 32 patients with DSM-IV Tourette's disorder. Mean tic severity scores from the Yale Global Tic Severity Scale after 14 sessions of treatment were significantly better in the HRT group (19.8 + 7.6) than in the control group (26.9 + 9.2, p < 0.05 by t test; p < 0.01 after controlling for baseline tic severity by ANCOVA). In addition, functional impairment ratings improved significantly, and significantly more, in the HRT group (p < 0.01 for each comparison). Patients rated themselves as significantly more improved with HRT (CGI score, mean 2.13 vs 3.55 in the supportive therapy group; p < 0.01). Unfortunately, these ratings were not done blind to treatment status.
    • one review concluded that the overall efficacy of HRT for tics is ~90% at home, ~80% in clinic, but later studies are not quite that enthusiastic
    • improvement seems to be independent of medication status or age, and generalizes over different settings
  • Evidence regarding side effects:
    • little data prior to the two large RCTs (Piacentini et al 2010; Wilhelm et al 2012), which prospectively monitored side effects and found none
    • the Discussion sections of these two reports specifically address and refute concerns by prominent clinicians who do not understand CBIT well, underestimate its benefit, expect side effects from CBIT that do not occur (or at worst are rare), and hence relegate it to a secondary role in treatment
    • however, even in older studies, there was no evidence of symptom substitution from videotape review or self-report (e.g., Azrin and Peterson 1990)
    • note that detailed questioning and blinded videotape review were performed in some studies; results suggest that patients generally end up using the behavior therapy techniques rarely, because tic frequency declines (i.e. patients don't just incorporate the behavior therapy technique as a new tic)
  • Method (the original components of HRT are described first; see Woods and Miltenberger 1995 for an excellent review of what works in HRT)
    • Awareness Training
      • first visit:subject & (spouse) to record frequency of each tic for a specified duration each day (10min or all day depending on frequency of tic); videotape subject at beginning of each session
      • Reponse Description Procedure: describe the detail of each tic to therapist, using mirror and/or videotape
      • Response Detection Procedure: therapist alerts subject each time a tic is observed, with progressively less intrusive warnings
      • Early Warning Procedure: subjects practice self-detection of earliest signs or sensory cues before a tic
      • Situation Awareness Training: subjects identify situations, persons or places in which symptoms were better or worse
    • Relaxation Training: progressive muscular relaxation, deep breathing, visual imagery, self-statements of relaxation; taught during first visit and instructed to practice at least daily for 10-15 minutes as well as for 1-2 minutes whenever anxious or whenever they have a tic
    • Competing Response Training (contingent)
      • "taught a specific response pattern that would be incompatible with the [tic]. . . . In addition, . . . (1) . . . opposite to the nervous movement, (2) capable of being maintained for several minutes, (3) . . . isometric tensing of the muscles involved in the movement, (4) . . . socially inconspicuous and easily compatible with normal ongoing activities . . . (5) strengthening the muscle antagonistic to the tic." (Azrin and Nunn 1973 p.623)
      • Examples of CRs are given in Carr 1995.
        • example: for head jerking back, the CR could be contraction of the neck flexors with chin slightly down and in
        • example: for a vocal tic, the CR could be slow rhythmic deep breathing through the nose with the mouth closed
      • The competing response is to be done for 3 minutes after each tic or sensation that a tic is about to occur.
      • Research suggests that only contingent use of the competing response is helpful (i.e. every time a tic or sensory tic happens), while non-contingent (e.g. random or scheduled) use of the competing response is not (Miltenberger and Fuqua 1985).
      • "Miltenberger, Fuqua and McKinley (1985) found that the awareness training and competing response training components used together were effective as the entire habit reversal program in suppressing muscle tics" (quoted from Miltenberger and Fuqua 1985).
      • Also, a study in 2 patients suggested that the competing response (CR) need not be truly competing; e.g. for a head-turning tic, a CR of pressing the foot into the floor works just as well as a head-turning CR (Sharenow et al 1989).
      • "The tic that was the most frequent or most disruptive was treated first after the relaxation training. At least one session was devoted to training the individual to employ the Competing Response Procedure both during the session and during the following week in the subject's natural home setting. In subsequent sessions, each additional tic was treated one at a time until a specific competing response had been established for each tic." (Azrin and Peterson 1988 p.349)
    • Contingency Management
      • family instructed to comment favorably on signs of improvement (and in Azrin and Nunn 1973 report, remind the patient to "do exercises" if he/she forgot)
      • Habit Inconvenience Review: therapist and subject reviewed inconveniences, embarrassment and suffering from tics plus positive aspects of eliminating tics; write notes on a card carried & reviewed frequently by subject
      • frequent praise from therapist (in 1973 paper, daily phone calls!)
      • participate in enjoyable activities that may have been avoided in the past
      • go into situations in which tic likely to occur and tell or show friends & family about the improved ability to control tics
    • Generalization Training: practice on how to control tics in everyday situations
      • practice procedures in session until done correctly
      • symbolic rehearsal: imagine common and tic-eliciting situations and then perform the exercise
      • practice the procedure for the rest of the session; therapist prompts subject if s/he forgets (see Azrin and Nunn 1973, p. 625)
    • Self-monitoring alone (e.g. keep count with a hand counter) has (possibly transient) but significant benefit
    • O'Connor adds cognitive therapeutic goals and strategies
    • Exposure and response prevention (E/RP) is also effective against tics, though there is much less evidence for its efficacy than there is for HRT/CBIT (Verdellen et al 2004).
    • Details of CBIT treatment are given in Woods et al, 2008 and other sources.

  • References:
    • Azrin NH, Nunn RG: Habit-reversal: A method of eliminating nervous habits and tics. Behav Res Ther 11:619-628, 1973.
    • Azrin NH, Nunn RG, Frantz SE: Habit reversal vs. negative practice treatment of nervous tics. Behav Ther 11:169-178, 1980.
    • Azrin NH, Peterson AL: Habit reversal for the treatment of Tourette Syndrome. Behav Res Ther 26:347-351, 1988.
    • Azrin NH, Peterson AL: Behavior therapy for Tourette's syndrome and tic disorders. Ch. 16 (pp. 237-255) in Cohen DJ, Bruun, RD, Leckman JF, eds., Tourette's syndrome and tic disorders: clinical understanding and treatment. New York, John Wiley & Sons, 1988.
    • Azrin NH, Peterson AL: Treatment of Tourette Syndrome by habit reversal: A waiting-list control group comparison. Behav Ther 21:301-318, 1990.
    • Capriotti M, Himle M, Woods D: Cognitive-behavioural treatment for tics. J Obsessive Compuls Relat Disord 2014 [in press].
    • Carr JE: Competing responses for the treatment of Tourette syndrome and tic disorders. Behav Res Ther 33:455-456, 1995.
    • Chambless DL, Baker MJ, Baucom DH, Beutler LE, Calhoun KS, Crits-Cristoph P, Daiuto A, DeRubeis R, Detweiler J, Haaga DAF, Johnson SB, McCurry S, Mueser KT, Pope KS, Sanderson WC, Shoham V, Stickle T, Williams DA, Woody SR: Update on empirically validated therapies, II. The Clinical Psychologist 51(1):3-16, 1998.
    • Cook CR, Blacher J: Evidence-based psychosocial treatments for tic disorders. Clinical Psychology: Science and Practice 14:252-267, 2007. doi: 10.1111/j.1468-2850.2007.00085.x
    • Leckman JF, King RA, Bloch MH: Clinical features of Tourette syndrome and tic disorders. J Obsessive Compuls Relat Disord 2014 [in press].
    • Miltenberger RG, Fuqua RW: A comparison of contingent vs non-contingent competing response practice in the treatment of nervous habits. J Behav Ther Exp Psychiatr 16:195-200, 1985.
    • Miltenberger RG, Fuqua RW, Woods DW: Applying behavior analysis to clinical problems: Review and analysis of habit reversal. J Appl Behav Anal 31:447-469, 1998.
    • O'Connor KP, Brault M, Robillard S, Loiselle J, Borgeat F, Stip E: Evaluation of a cognitive-behavioural program for the management of chronic tic and habit disorders. Behav Res Ther 39:667-681, 2001.
    • O'Connor KP: Personal communication to Kevin Black, 2001 and 2003.
    • Peterson AL, Azrin NH: An evaluation of behavioral treatments for Tourette Syndrome. Behav Res Ther 30:167-174, 1992.
    • Peterson AL, Campise RL, Azrin NH: Behavioral and pharmacological treatments for tic and habit disorders: A review. J Dev Behav Pediatr 15:430-441, 1994.
    • Piacentini J, Woods DW, Scahill L, Wilhelm S, Peterson AL, Chang S, Ginsburg GS, Deckersbach T, Dziura J, Levi-Pearl S, Walkup JT: Behavior therapy for children with Tourette Disorder: A randomized controlled trial. J Am Med Assoc 303(19):1929-1937, 2011 (doi: 10.1001/jama.2010.607) [Note: Dr. Piacentini confirmed by email to KJB 6/27/2011 that tics had to cause "some level of impairment" or distress for a subject to be included in this study.]
    • Sharenow EL, Fuqua RW, Miltenberger RG: The treatment of muscle tics with dissimilar competing response practice. J Appl Behav Anal 22(1):35-42, 1989.
    • Steeves T, McKinlay BD, Gorman D, Billinghurst L, Day L, Carroll A, Dion Y, Doja A, Luscombe S, Sandor P, Pringsheim T: Canadian guidelines for the evidence-based treatment of tic disorders: behavioural therapy, deep brain stimulation, and transcranial magnetic stimulation. Can J Psychiatry 57(3):144-151, 2012.
    • Verdellen CW, Keijsers GP, Cath DC, Hoogduin CA: Exposure with response prevention versus habit reversal in Tourettes's syndrome: a controlled study. Behav Res Ther 42:501-511, 2004.
    • Verdellen, C., van de Griendt, J., Hartmann, A., Murphy, T., & ESSTS Guidelines Group. (2011). European clinical guidelines for Tourette syndrome and other tic disorders. Part III: behavioural and psychosocial interventions. European Child and Adolescent Psychiatry, 20, 197-207. doi:10.1007/s00787-011-0167-3
    • Wilhelm S, Deckersbach T, Coffey BJ, Bohne A Peterson AL, Baer L: Habit reversal versus supportive psychotherapy for Tourette's disorder: A randomized controlled trial. Am J Psychiatry 160:1175-1177, 2003.
    • Wilhelm S, Peterson AL, Piacentini J, Woods DW, Deckersbach T, Sukhodolsky DG, Chang S, Liu H, Dziura J, Walkup JT, Scahill L: Randomized trial of behavior therapy for adults with Tourette syndrome. Arch Gen Psychiatry 69(8):795-803, 2012.
    • Woods DW, Miltenberger RG: Habit reversal: A review of applications and variations. J Behav Ther Exp Psychiatry 26(2):123-131, 1995. doi: 10.1016/0005-7916(95)00009-O
    • Woods DW, Miltenberger RG, Lumley VA: Sequential application of major habit-reversal components to treat motor tics in children. J Appl Behav Anal 29:483-493, 1996.
    • Woods DW, Piacentini J, Chang S, Deckersbach T, Ginsburg G, Peterson A, Scahill LD, Walkup JT, Wilhelm S: Managing Tourette Syndrome: A Behavioral Intervention for Children and Adults Therapist Guide. Treatments That Work series. New York: Oxford University Press, 2008. available at Amazon.com
    • Woods DW, Piacentini JC, Scahill L, Peterson AL, Wilhelm S, Chang S, Deckersbach T, McGuire J, Specht M, Conelea CA, Rozenman M, Dzuria J, Liu H, Levi-Pearl S, Walkup JT: Behavior therapy for tics in children: acute and long-term effects on psychiatric and psychosocial functioning. J Child Neurol 26(7):858-865, 2011.



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